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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Medicare drug appeals, clinical patient care, and regulatory compliance while effectively collaborating with cross-functional teams to enhance value-based care for members. Holds a strong foundation in utilization management and clinical guidelines to support optimal decision-making.
Highest-signal resume keywords
MD Or DO Degree5+ Years Clinical Patient Care ExperienceBoard Certification In Internal Medicine, Family Medicine, Emergency Medicine, Or Physical Medicine And RehabilitationUtilization Management ExperienceKnowledge Of Managed Care Industry
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medicare Drug Appeals ReviewClinical Literature AnalysisPeer-To-Peer DiscussionsRegulatory ComplianceAnalytic And Interpretation SkillsQuality ManagementUtilization ManagementExposure To Public HealthBusiness Metrics AnalysisCredentialing Requirements
Soft Skills
Excellent Verbal Communication SkillsExcellent Written Communication SkillsTeam Collaboration
Tools & Technologies
MCGInterQualNCCNMicromedexLexicompElsevier's Clinical Pharmacology
Certifications & Qualifications
Current And Unrestricted Physician LicenseBoard Certification
Industry Keywords
Medicare Part DMedicare AdvantageIntegrated Delivery SystemsHealth InsuranceClinical Group Practice Management
About the role
Key responsibilities & impact- Review Medicare drug appeals under Part D and Part B
- Analyze moderately complex to complex cases using Medicare rules, Humana policies, medical necessity criteria, CMS policies, coverage determinations, recognized compendia, clinical literature, and departmental resources
- Conduct peer-to-peer discussions with prescribers
- Participate in hearings involving an Administrative Law Judge
- Support CMS audits
- Participate in cross-functional team activities
- Collaborate with clinicians and support staff to provide Humana members with optimal value-based care
- Learn Medicare Part D and Medicare Advantage requirements and operationalize them in daily work
- Perform all work within regulatory compliance requirements
- Travel occasionally to Humana offices for training or meetings
Requirements
What you’ll need- MD or DO degree
- 5+ years of direct clinical patient care experience post completion of doctorate
- 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 additional license, if required
- No current sanction from Federal or State Governmental organizations
- Ability to pass credentialing requirements
- Excellent verbal and written communication skills
- Evidence of analytic and interpretation skills
- Prior experience participating in teams focusing 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 a medical management review organization such as 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
- Experience functioning as a team member
- Minimum home internet speed of 25 Mbps download and 10 Mbps upload
- Ability to work from a dedicated space without ongoing interruptions to protect member PHI/HIPAA information
Benefits
Comp & perks- Bonus incentive plan based on company and/or individual performance
- Medical benefits
- Dental benefits
- Vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company holidays
- Personal holidays
- Paid parental leave
- Paid caregiver leave
- Short-term disability
- Long-term disability
- Life insurance
- Telephone equipment appropriate to business requirements for Home or Hybrid Home/Office employees
- Bi-weekly internet expense payment for employees who live and work from home in California, Illinois, Montana, or South Dakota