Medical Director -Pharmacy Appeals

The Medical Director relies on broad clinical expertise to review Medicare drug appeals (Part D &

B). The Medical director works assignments involve that 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 rules.

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.

• 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, utilization management, or similar activities

• 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, Inter Qual, 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

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