Remote Medical Director, Medicare Drug Appeals

Humana Inc; Santa Fe (NM); 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. The role involves case-by-case analysis of Medicare rules, Humana policies and medical necessity to support value-based care.

Collaboration with clinicians and staff, peer discussions with prescribers, and participation in audits and hearings are key activities; compliance with CMS guidance and Humana policy is essential.

Qualifications

• MD or DO degree required.
• 5+ years of direct clinical patient care experience post doctorate.
• Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation.
• Current and unrestricted physician license in at least one jurisdiction and willingness to obtain additional licenses if required.
• No current sanction from Federal or State Governmental organizations and ability to pass credentialing.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills with experience in quality or utilization management.

Responsibilities

• Review Medicare drug appeals (Part D & B) using Medicare rules and Humana policies.
• Collaborate with clinicians and staff to provide Humana members with value-based care.
• Work with cross-functional teams, participate in hearings involving an Administrative Law Judge, and support CMS audits.
• Engage in Peer-to-Peer discussions with prescribers and support regulatory compliance.

Skills

Board Certification

Strong communication

Analytic interpretation

Team collaboration

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. The role involves case-by-case analysis of Medicare rules, Humana policies and medical necessity to support value-based care.

Collaboration with clinicians and staff, peer discussions with prescribers, and participation in audits and hearings are key activities; compliance with CMS guidance and Humana policy is essential.