[Remote] Medical Director - Pharmacy Appeals at Humana

San Antonio, Texas, United States

Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

MD or DO degree
5+ years of direct clinical patient care experience post residency or fellowship
Current and unrestricted license in at least one jurisdiction
Ability to obtain additional license, if required
No current sanction from Federal or State Governmental organizations
Ability to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills
Prior experience participating in teams focusing on quality management, utilization management, or similar activities

Responsibilities

Review Medicare drug appeals (Part D & B) using broad clinical expertise
Collaborate with clinicians and support staff to provide Humana members with optimal value-based care
Operate within a context of regulatory compliance
Utilize diverse resources, including CMS policies, National and Local Coverage Determinations, and clinical literature
Conduct computer-based review of moderately complex to complex appeals for coverage of drugs
Participate in Peer to Peer discussions with prescribers
Participate in hearings involving an Administrative Law Judge
Support for CMS audits
Cross-functional team activities
Other responsibilities as determined necessary to support optimal value-based care in accordance with Medicare and Humana policy

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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