Medical Director - Pharmacy

Description

: The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D & B). The Medical director work 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.

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 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.

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 Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation
• 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, Integrated Delivery Systems, health insurance, or 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
• 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

#physiciancareers

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$199,400 - $274,400 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.