Remote Medicare Appeals Director

Humana Inc; Topeka (KS); Remote; USD 224,000 - 313,000; Full time

Job summary

Humana Inc. seeks a Medical Director to oversee Medicare drug appeals (Part D & B). You will apply broad clinical expertise to review complex cases, using Medicare rules, Humana policies, and medical necessity to determine coverage decisions.

This remote, full-time role requires collaboration with clinicians, cross-functional teams, and participation in hearings or CMS audits. You will help operationalize Medicare Part D and MA requirements in daily work, ensuring compliant, value-based care for

Qualifications

• MD or DO degree.
• 5+ years of direct clinical patient care experience after doctorate.
• Current and ongoing Board Certification.
• Active physician license in at least one jurisdiction.
• No sanctions and able to pass credentialing requirements.
• Excellent verbal and written communication skills.
• Evidence of analytic and interpretation skills.

Responsibilities

• Review Medicare drug appeals (Part D & B) using Humana policies and Medicare rules.
• Collaborate with clinicians and staff to ensure value-based care for Humana members.
• Participate in hearings with administrative law judges and support CMS audits.
• Engage in cross-functional teams to improve utilization management and quality.
• Stay current with national guidelines and clinical literature.

Skills

Board Certification

Clinical expertise

Analytic skills

Communication skills

Licensure

Team collaboration

Education

MD or DO degree

Job description

Humana Inc. seeks a Medical Director to oversee Medicare drug appeals (Part D & B). You will apply broad clinical expertise to review complex cases, using Medicare rules, Humana policies, and medical necessity to determine coverage decisions.

This remote, full-time role requires collaboration with clinicians, cross-functional teams, and participation in hearings or CMS audits. You will help operationalize Medicare Part D and MA requirements in daily work, ensuring compliant, value-based care for