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.