Medical Director – Pharmacy Appeals

Darum lohnt es sich

• 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.

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 Holds a current physician license and board certification, ensuring compliance with healthcare regulations and standards.