Remote Medical Director, Medicare Appeals

Humana Inc; United States; Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to review Medicare drug appeals (Part D & B) and guide coverage decisions in a remote environment.

The role involves case-by-case analysis of Medicare rules, Humana policies, and medical necessity, with collaboration across clinical teams to support optimal value-based care for members. The position requires an MD/DO with 5+ years of direct clinical care, board certification, an active license, and strong communication and analytical skills.

Qualifications

• MD or DO with 5+ years direct clinical patient care experience.
• Board certification in Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation.
• Active physician license in at least one state, willing to obtain additional licenses if required.
• No current sanctions from Federal or State authorities; able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills with experience in quality/utilization management.

Responsibilities

• Review Medicare drug appeals (Part D & B) using Medicare rules, Humana policies, and medical necessity.
• Collaborate with clinicians and support staff to deliver value-based care.
• Participate in peer discussions, hearings (Administrative Law Judge), CMS audits, and cross-functional teams.

Skills

Clinical experience

Board Certification

Medical licensure

Analytical skills

Communication skills

Education

MD/DO

Job description

Humana Inc. is seeking a Medical Director to review Medicare drug appeals (Part D & B) and guide coverage decisions in a remote environment.

The role involves case-by-case analysis of Medicare rules, Humana policies, and medical necessity, with collaboration across clinical teams to support optimal value-based care for members. The position requires an MD/DO with 5+ years of direct clinical care, board certification, an active license, and strong communication and analytical skills.