Medical Director – Pharmacy Appeals

• Review Medicare drug appeals for Part D and Part B coverage
• Analyze moderately complex to complex cases using Medicare rules, Humana policies, medical necessity criteria, CMS policies, coverage determinations, recognized compendia, clinical guidelines, and literature
• Conduct computer-based reviews of drug coverage appeals
• Participate in peer-to-peer discussions with prescribers
• Participate in hearings involving an Administrative Law Judge
• Support CMS audits
• Collaborate with clinicians, support staff, and inter- and intra-departmental resources
• Participate in cross-functional team activities
• Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work
• 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 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
• Current and unrestricted physician license in at least one jurisdiction
• Willingness to obtain an additional license if required
• No current sanction from Federal or State Governmental organizations
• Able to pass credentialing requirements
• Excellent verbal and written communication skills
• Evidence of analytic and interpretation skills
• Prior experience participating in teams focused 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 Medicare Advantage, managed Medicaid, or Commercial health insurance
• Experience with national guidelines such as MCG, InterQual, NCCN, Micromedex, Lexicomp, and 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
• Minimum 25 Mbps download and 10 Mbps upload internet speed for home or hybrid home/office work
• Ability to work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information

Core Competencies

Demonstrates expertise in Medicare drug appeals, clinical guidelines, and utilization management, with a strong foundation in patient care and collaboration across multidisciplinary teams. Holds a current physician license and board certification, ensuring compliance with healthcare regulations and standards.

Highest-signal resume keywords

• MD Or DO Degree
• 5+ Years Clinical Patient Care Experience
• Board Certification In Internal Medicine, Family Medicine, Emergency Medicine, Or Physical Medicine And Rehabilitation
• Utilization Management Experience In Medicare Advantage
• Knowledge Of Managed Care Industry

Hard Skills

• Medicare Drug Appeals Review
• Clinical Guidelines Analysis
• Utilization Management
• Analytic And Interpretation Skills
• Peer-To-Peer Discussions
• Support CMS Audits
• Cross-Functional Team Collaboration
• Knowledge Of National Guidelines (MCG, InterQual, NCCN)
• Public Health And Population Health Analytics
• Business Metrics Utilization

Soft Skills

• Excellent Verbal And Written Communication Skills
• Curiosity To Learn
• Flexibility To Adapt
• Courage To InnovateTeam Collaboration

Certifications & Qualifications

• Current And Unrestricted Physician License
• Board Certification

Industry Keywords

• Medicare Part D
• Medicare Advantage
• Clinical Group Practice Management
• Integrated Delivery Systems
• Health Insurance
• Quality Management
• Utilization Management
• CMS Policies
• Medical Necessity Criteria
• PHI/HIPAA Compliance