Medical Director – Medicare Pharmacy Appeals, Part Time, Seasonal - Remote Eligible

Become a Part of Our Caring Community and Help Us Put Health First

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. Please note that this Medical Director position is non-benefitted, and compensated hourly.

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.

Use your skills to make an impact.

Required Qualifications:

• MD or DO degree
• 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
• 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)
• 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

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours: 1

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 will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $223,800 - $313,100 per year

Description of Benefits: Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers benefits for limited term, variable schedule and per diem associates which are designed to support whole-person well-being. Among these benefits, Humana provides paid time off, 401(k) retirement savings plan, employee assistance program, business travel and accident. Application Deadline: 01-31-2026

About Us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer: It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.