# Medical Director

**Company**: Humana Inc.
**Location**: Remote Nationwide
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $223,800 - $313,100 per year
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://humana.wd5.myworkdayjobs.com/en-US/Humana_External_Career_Site/job/Remote-Nationwide/Medical-Director--Pharmacy-Appeals_R-435017?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/jobs/job_6dea11dd-44d

## Description

The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical Director's work involves moderately complex to complex issues where analysis of situations or data requires a case-by-case consideration of Medicare rules, Humana policies, and medical necessity.

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, including CMS policies, National and Local Coverage Determinations, CMS-recognised Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature as appropriate.

**Responsibilities**

- Conduct 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.

- Engage in Peer to Peer discussions with prescribers, participate 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.

**Requirements**

- 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.

- Excellent verbal and written communication skills.

- Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilisation management, or similar activities.

**Preferred Qualifications**

- Knowledge of the managed care industry, Integrated Delivery Systems, health insurance, or clinical group practice management.

- Utilisation management experience in a medical management review organisation 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.

**Benefits**

- Competitive benefits that support whole-person well-being, including medical, dental and vision benefits, 401(k) retirement savings plan, time off, short-term and long-term disability, life insurance, and more.

**Schedule**

- 40 scheduled weekly hours.

- Remote work arrangement with occasional travel to Humana's offices for training or meetings.

**Pay Range**

- $223,800 - $313,100 per year.

## Skills

### Required
- MD or DO degree
- Board Certification
- physician license
- verbal and written communication skills
- analytic and interpretation skills

### Nice to have
- managed care industry
- utilisation management experience
- national guidelines
- Public Health
- Population Health
- analytics

---

Source: [Apply at humana.wd5.myworkdayjobs.com](https://humana.wd5.myworkdayjobs.com/en-US/Humana_External_Career_Site/job/Remote-Nationwide/Medical-Director--Pharmacy-Appeals_R-435017?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)