Medical director – medicare pharmacy, vsp

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 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 other responsibilities as determined necessary to support optimal value-based care in accordance with Medicare and Humana policy.

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

Use your skills to make an impact

Required Qualifications:

• MD or DO degree
• A current and unrestricted license in at least one jurisdiction and willing to obtain additional license, if required
• Current and ongoing Board Certification with preference for Internal Medicine, Family Medicine, Emergency Medicine or Physical Medicine and Rehabilitation
• 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

Work at home requirements:

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

SSN Alert:

Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana's secure website.

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:

09-20-2026

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our 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 and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.

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.