Medical Director -Pharmacy Appeals

Become a part of our caring community   The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director works assignments involve moderately complex to complex issues where the analysis of situations or data requires a case-by-case consideration of the Medicare rules, Humana policies and medical necessity. The Medical Director's work includes computer-based review of moderately complex to complex appeals for coverage for drugs using resources outlined above as well as inter- and intra-departmental resources. Work may include Peer to Peer discussions with prescribers, participation in hearings involving an Administrative Law Judge, support for CMS audits, cross-functional team activities, and other responsibilities as determined necessary to support optimal value-based care in accordance with Medicare and Humana policy. The Medical Director will collaborate with clinicians and support staff to provide Humana members with optimal value-based care in accordance with Medicare and Humana policy. All work occurs within a context of regulatory compliance and work is assisted by diverse resources, included but not limited to CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature as appropriate. Medical Directors will learn Medicare Part D and Medicare Advantage requirements and will understand how to operationalize this in their daily work. The Medical Director's work includes computer-based review of moderately complex to complex appeals for coverage for drugs using resources outlined above as well as inter- and intra-departmental resources. Work may include Peer to Peer discussions with prescribers, participation in hearings involving an Administrative Law Judge, support for CMS audits, cross-functional team activities, and other responsibilities as determined necessary to support optimal value based care in accordance with Medicare and Humana policy. Use your skills to make an impact   Required Qualifications: MD or DO degree 5+ years of direct clinical patient care experience post completion of doctorate, preferably including some experience related to a Medicare type population (disabled or >65 years of age) Current and ongoing Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation A current and unrestricted physician license in at least one jurisdiction and willing to obtain additional license, if required No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements Excellent verbal and written communication skills Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities Preferred Qualifications: Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management Utilization management experience in a medical management review organization such as Medicare Advantage, managed Medicaid, or Commercial health insurance Experience with national guidelines, such as MCG, InterQual, NCCN, Micromedex, Lexicomp, Elsevier's Clinical Pharmacology Exposure to Public Health, Population Health, analytics, and use of business metrics Curiosity to learn, flexibility to adapt, courage to innovate Experience functioning as a Team member, providing support to reach a common goal Additional Information : Work at home requirements: To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave