[Remote] Medical Director – Medicare Pharmacy Appeals, Part Time, Seasonal at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Part TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

MD or DO degree
Current and unrestricted 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 (treated as preferred requirements)
Current and ongoing Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation
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
5+ years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age)
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

Responsibilities

Review Medicare drug appeals (Part D & B) relying on broad clinical expertise, analyzing moderately complex to complex issues on a case-by-case basis considering Medicare rules, Humana policies, and medical necessity
Collaborate with clinicians and support staff to provide Humana members with optimal value-based care in accordance with Medicare and Humana policy
Conduct computer-based review of moderately complex to complex appeals for coverage for drugs using resources such as CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature
Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work
Participate in Peer to Peer discussions with prescribers
Participate in hearings involving an Administrative Law Judge
Support CMS audits
Engage in cross-functional team activities
Perform other responsibilities as determined necessary to support optimal value-based care in accordance with Medicare and Humana policy
Occasional travel to Humana's offices for training or meetings (remote position)

Skills

Key technologies and capabilities for this role

MDDOMedicare Part DMedicare Part BPharmacy AppealsMedical Necessity ReviewCMS PoliciesPeer to Peer DiscussionsRegulatory Compliance

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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