Corporate Medical Director - Medicare Grievances and Appeals (32-Hours…
HumanaFull Time
Senior (5 to 8 years)
Candidates must possess an active and unencumbered pharmacist license in their state of residence, along with current experience as a clinical pharmacist reviewing Medicare Part D requests within a Caremark PBM environment. Proficiency in utilizing multiple software systems simultaneously on a dual-screen workstation, including Windows-based operations, AS400, MHK, PeopleSafe, WI database, and Microsoft Office applications, is required. A typing speed of 30 WPM or greater, excellent oral and written communication skills, and the ability to multitask, prioritize, and manage time effectively in a fast-paced, highly regulated environment are essential. Candidates must be able to review large volumes of information, discern importance, apply clinical knowledge for outcomes, work independently, utilize critical thinking and problem-solving skills for case decisions, and be receptive to feedback and adaptable to change. Flexibility with a rotating schedule including overtime, weekends, and holidays is necessary, along with a dedicated, secure, and uninterrupted home workspace with stable, hard-wired high-speed internet. A BS in Pharmacy or PharmD and 3+ years of experience in a Managed Care/PBM environment are preferred.
The RPh Operations Advisor will directly support Medicare Part D members and providers with requests concerning their pharmacy benefits. Key responsibilities include accurately setting up cases for members, reviewing clinical information for decision-making, performing outreach to providers for additional information when needed, and ensuring accurate decisions that comply with compendia and Medicare guidance and timelines. This role involves reviewing information and completing timely and accurate documentation of all Medicare Part D requests in compliance with Medicare guidelines, while promoting a best-in-class service experience.
Comprehensive pharmacy and healthcare services
CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.