Medical Director - Medicare Appeals
CVS HealthSalary not specified
Full Time
Mid-level (3 to 4 years)
Not SpecifiedCompensation
N/AExperience Level
N/AJob Type
Not SpecifiedVisa
N/AIndustries
Requirements
- MD or DO degree
- Current and unrestricted license in at least one jurisdiction
- No current sanction from Federal or State Governmental organizations
- Excellent verbal and written communication skills
- Evidence of analytic and interpretation skills
- Experience participating in teams focusing on quality management, utilization management, or similar activities
Responsibilities
- Review Medicare drug appeals (Part D & B)
- Collaborate with clinicians and support staff to provide optimal value-based care
- Computer-based review of moderately complex to complex appeals for drug coverage
- Conduct Peer to Peer discussions with prescribers
- Participate in hearings involving an Administrative Law Judge
- Support CMS audits
- Participate in cross-functional team activities
- Learn Medicare Part D and Medicare Advantage requirements
- Operationalize Medicare requirements in daily work
- Utilize resources such as CMS policies, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature
Skills
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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