Remote Medical Director: Medicare Appeals & ValueBasedCare

Humana Inc; Jackson (MS); 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) leveraging broad clinical expertise. You will analyze complex cases, collaborate with clinicians, and support CMS audits to ensure value-based care within Medicare rules.

Responsibilities include peer discussions, interdepartmental coordination, and applying Humana policies and clinical literature. A licensed MD/DO with board certification and 5+ years of direct care is required.

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care post doctorate.
• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or PM&R.
• Active medical license in at least one jurisdiction.
• Willing to obtain additional license if required.
• Excellent verbal and written communication skills.
• Experience with quality/utilization management teams.

Responsibilities

• Review Medicare drug appeals (Part D & B) using clinical expertise and Medicare rules.
• Collaborate with clinicians and support staff to provide value-based care.
• Engage in Peer to Peer discussions with prescribers and participate in hear-ings with an Administrative Law Judge.
• Support CMS audits and cross-functional team activities as needed.

Skills

5+ years direct clinical care

Board Certification

Medical license

Excellent verbal and written comms

Analytic & interpretation skills

Credentialing knowledge

Education

MD or DO degree

Job description

Humana Inc. is seeking a Medical Director to review Medicare drug appeals (Part D & B) leveraging broad clinical expertise. You will analyze complex cases, collaborate with clinicians, and support CMS audits to ensure value-based care within Medicare rules.

Responsibilities include peer discussions, interdepartmental coordination, and applying Humana policies and clinical literature. A licensed MD/DO with board certification and 5+ years of direct care is required.