Remote Medicare Appeals Medical Director

Humana, Inc.; Bismarck (ND); Teletrabalho; USD 224 000 - 313 000; Tempo integral

Resumo da oferta

Humana, Inc. seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. 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 and staff to ensure optimal patient outcomes while maintaining regulatory compliance. Responsibilities include peer discussions, CMS audit support, and cross-functional teamwork across Humana policies and clinical

Qualificações

• MD or DO degree.
• 5+ years of direct clinical patient care post-licensure.
• Board Certification in Internal/Family/Emergency/PM&R preferred.
• Current unrestricted physician license in at least one jurisdiction.
• Willingness to obtain additional licenses if required.
• Excellent verbal and written communication skills.
• Experience with quality/utilization management or similar initiatives.

Responsabilidades

• Review Medicare drug appeals (Part D & B) for coverage decisions.
• Collaborate with clinicians and staff to ensure value-based care.
• Analyze complex cases with Medicare rules and Humana policies.
• Support CMS audits and cross-functional team activities.
• Engage in peer discussions with prescribers and participate in hearings.

Conhecimentos

MD/DO degree

Clinical patient care

Board Certification

Medical license

Credentialing

Communication skills

Analytic/interpretation skills

Formação académica

MD or DO degree

Descrição da oferta de emprego

Humana, Inc. seeks a Medical Director to review Medicare drug appeals (Part D & B) with broad clinical expertise. 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 and staff to ensure optimal patient outcomes while maintaining regulatory compliance. Responsibilities include peer discussions, CMS audit support, and cross-functional teamwork across Humana policies and clinical