Medical Director - Medicare Pharmacy Appeals

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Job Information
Humana
Medical Director - Medicare Pharmacy Appeals
in
Fargo
North Dakota
Description
The Medical Director relies on clinical background and reviews Medicare drug requests. The Medical director work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
Candidates may live anywhere within the US and be willing to work Central or East hours.
Responsibilities
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, included but not limited to CMS policies, National and Local Coverage Determinations, CMS-recognized Compendia, NCCN, Humana Pharmacy Policies and Procedures, and clinical literature as appropriate. Medical Directors will learn Medicare and Medicare Advantage requirements and will understand how to operationalize this in their daily work.
The Medical Director's work includes 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. Work may include Peer to Peer discussions with prescribers, participation 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.
Required Qualifications:
MD or DO degree
5 years of direct clinical patient care experience post residency or fellowship, preferably including some experience related to a Medicare type population (disabled or >65 years of age)
Current and ongoing Board Certification in an approved ABMS Medical Specialty
A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
No current sanction from Federal or State Governmental organizations, and able to pass credentialing requirements
Excellent verbal and written communication skills
Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, or similar activities
Preferred Qualifications:
Knowledge of the managed care industry, including Medicare, Medicare Advantage, Managed Medicaid and/or Commercial products, or other Medical management organizations, hospitals/Integrated Delivery Systems, health insurance, or other healthcare providers, clinical group practice management
Utilization management experience in a medical management review organization, 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, PAHub.
Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialists
Exposure to Public Health, Population Health, analytics, and use of business metrics
Curiosity to learn, flexibility to adapt, courage to innovate
Experience functioning as a Team member, providing support to reach a common goal
Additional Information
For this job, associates are required to be fully COVID vaccinated or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home. We are a healthcare company committed to putting health and safety first for our members, patients, associates, and the communities we serve.
If progressed to offer, you will be required to:
Provide proof of full vaccination or commit to testing protocols
*OR  *
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
#physiciancareers
Scheduled Weekly Hours
40

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