Medical Director -Pharmacy Appeals

**Become a part of our caring community** ========================================= The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D \& B). The Medical director works assignments involve moderately complex to complex issues where the analysis of situations or data requires a case\-by\-case consideration of the Medicare rules, Humana policies and medical necessity. 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. 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 Part D 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. **Use your skills to make an impact** ===================================== **Required Qualifications:** * 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 * 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