Remote Medical Director: Medicare Drug Appeals Expert

Humana Inc; Honolulu (HI); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. in the United States seeks a Medical Director to apply broad clinical expertise reviewing Medicare Part D and Part B drug appeals.

The role involves case-by-case analysis of Medicare rules, Humana policies, and medical necessity to support value-based care. You will collaborate with clinicians, participate in cross-functional teams, and engage in peer discussions, CMS audits, and hearings as needed.

Qualifications

• MD/DO degree required
• Current and unrestricted physician license
• Board Certification in preferred specialties
• No sanctions and credentialing clear
• Excellent verbal and written communication
• Analytic and interpretation skills with team experience

Responsibilities

• Review Medicare drug appeals (Part D & B) with broad clinical expertise
• Conduct computer-based reviews of moderately complex to complex cases
• Engage in Peer to Peer discussions with prescribers and CMS hearings as needed
• Support CMS audits and cross-functional team activities
• Collaborate with clinicians to ensure value-based care for Humana members

Skills

Verbal communication

Written communication

Analytic skills

Team collaboration

Education

MD/DO degree

Board Certification

Medical license

Job description

Humana Inc. in the United States seeks a Medical Director to apply broad clinical expertise reviewing Medicare Part D and Part B drug appeals.

The role involves case-by-case analysis of Medicare rules, Humana policies, and medical necessity to support value-based care. You will collaborate with clinicians, participate in cross-functional teams, and engage in peer discussions, CMS audits, and hearings as needed.