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 v