Remote Medical Director — Medicare Appeals & Value-Based Care

Humana Inc; Nashville (TN); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. is seeking a Medical Director to provide expert clinical review of Medicare drug appeals (Part D & B) and support value-based care within Humana policies and Medicare rules.

You will analyze moderately to complex cases, collaborate with prescribers, and participate in hearings or CMS audits as needed. You will work with clinicians and staff to ensure optimal member care, balancing regulatory compliance with Humana policy, using CMS guidelines and recognized pharmacology resources to

Qualifications

• MD or DO degree.
• Current and ongoing Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation
• A current and unrestricted physician license in at least one jurisdiction and willing to obtain additional license, if required
• No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
• Excellent verbal and written communication skills
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities

Responsibilities

• Review Medicare drug appeals (Part D & B) using Medicare rules, Humana policies and medical necessity.
• Collaborate with clinicians and support staff to provide Humana members with optimal value-based care.
• Participate in hearings involving an Administrative Law Judge and support CMS audits.
• Work with cross-functional teams to support value-based care initiatives in accordance with Medicare and Humana policy.

Skills

Verbal and written communication

Analytic and interpretation skills

Education

MD or DO degree

Board Certification in Internal/Family/Emergency/PM&R

Active license in at least one jurisdiction

Job description

Humana Inc. is seeking a Medical Director to provide expert clinical review of Medicare drug appeals (Part D & B) and support value-based care within Humana policies and Medicare rules.

You will analyze moderately to complex cases, collaborate with prescribers, and participate in hearings or CMS audits as needed. You will work with clinicians and staff to ensure optimal member care, balancing regulatory compliance with Humana policy, using CMS guidelines and recognized pharmacology resources to