Remote Medical Director: Medicare Appeals & ValueBased Care

Humana Inc; Hartford (CT); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. in the United States seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. You will analyze complex cases, apply Medicare rules and Humana policies to determine coverage decisions.

The role involves computer-based reviews, peer discussions with prescribers, potential hearings, CMS audits and cross-functional collaboration to support value-based care. Travel may be required for trainings or meetings.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care experience post completion of doctorate.
• Current and ongoing Board Certification.
• Active license in at least one jurisdiction and ability to obtain additional license.
• No sanctions and ability to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Analytic and interpretation skills with team experience in quality/utilization management.

Responsibilities

• Review Medicare drug appeals (Part D & B) using Medicare rules and Humana policies.
• Computer-based review of moderately complex to complex drug coverage appeals.
• Peer-to-peer discussions with prescribers and participation in hearings.
• Support CMS audits and cross-functional team activities.
• Operationalize Medicare Part D and MA requirements in daily work.

Skills

MD or DO degree

Clinical experience

Board Certification

Medical license

Credentialing

Communication skills

Analytic skills

Education

MD or DO degree

Job description

Humana Inc. in the United States seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. You will analyze complex cases, apply Medicare rules and Humana policies to determine coverage decisions.

The role involves computer-based reviews, peer discussions with prescribers, potential hearings, CMS audits and cross-functional collaboration to support value-based care. Travel may be required for trainings or meetings.