Medical Director -Pharmacy Appeals

About This Opportunity

Our talent team is representing a confidential healthcare organization seeking a Medical Director to oversee pharmacy appeals. In this remote role, you'll apply your clinical expertise to review Medicare drug appeals, conducting computer-based assessments of moderately complex to complex cases. You'll evaluate coverage requests using federal regulations, national coverage determinations, recognized compendia, and clinical literature to ensure members receive appropriate care within regulatory frameworks.

This position offers the flexibility of remote work from anywhere in the United States, with occasional travel for training or meetings.

Responsibilities

• Review Medicare Part D and Part B drug appeals, analyzing cases that require individualized consideration of Medicare rules and medical necessity
• Conduct computer-based evaluations of coverage requests for prescription drugs using national guidelines and clinical resources
• Participate in peer-to-peer discussions with prescribing physicians to review clinical rationale
• Support administrative law judge hearings and federal audits as needed
• Collaborate with cross-functional clinical teams and support staff to ensure regulatory compliance
• Apply Medicare Advantage requirements and Part D regulations in daily decision-making
• Contribute to quality management and utilization management initiatives

What We're Looking For

Required Qualifications:

• MD or DO degree
• 5+ years of direct clinical patient care experience post-doctorate, preferably with Medicare-eligible populations (disabled or 65+ years)
• Current board certification (preference for Internal Medicine, Family Medicine, Emergency Medicine, or Physical Medicine and Rehabilitation)
• Current unrestricted physician license in at least one U.S. jurisdiction; willingness to obtain additional licenses if required
• Clean federal and state sanction record; ability to pass credentialing requirements
• Excellent verbal and written communication skills
• Demonstrated analytical and interpretation skills with prior team-based quality or utilization management experience
• Home internet meeting minimum 25 Mbps download/10 Mbps upload speeds
• Dedicated workspace to protect HIPAA/PHI information

Preferred Qualifications:

• Knowledge of managed care, Medicare Advantage, managed Medicaid, or commercial health insurance
• Utilization management experience in medical review organizations
• Familiarity with national guidelines such as MCG, InterQual, NCCN, Micromedex, Lexicomp, or similar resources
• Experience in population health, public health analytics, or business metrics
• Adaptability and collaborative team approach

How We Work With You

When you apply through Get A Job.ai, our recruiting team will review your credentials and conduct an initial screening. If we determine you're a strong match, we'll submit your profile to our client for consideration. Please do not contact the employer directly—all communication flows through our team to ensure a professional, coordinated process.

Pay

This role offers competitive compensation. Pay details will be discussed during the screening process based on your experience and qualifications.

Equal Employment Opportunity: Get A Job.ai is committed to inclusive hiring practices and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or veteran status.