Pharmacy Appeals Lead Medical Director

Pharmacy Appeals Lead Medical DirectorBecome a part of our caring community and help us put health first. Position Summary The Pharmacy Appeals Lead Medical Director is a dual focused role that combines clinical case production with protected administrative leadership time. This leader will oversee the operational and clinical excellence of the VSP Physician Program and serve as a key clinical partner across appeals, audits, and pharmacy operations. The ideal candidate is motivated, collaborative, clinically astute, and committed to continuously improving processes while keeping member impact at the forefront of every decision. Candidate Attributes A successful candidate will: Be highly motivated and accountable. Thrive in a collaborative, team-oriented environment. Think creatively about operational and clinical improvements. Approach work with a strong member-first perspective. Demonstrate exceptional clinical judgment and analytical reasoning. Key Responsibilities Program Leadership & Oversight Oversee and supervise the VSP Physician Program, ensuring high-quality performance across: Quality review Hiring and onboarding Training and skill development Midyear performance evaluation Workforce management (WFM) Productivity metric design and monitoring Escalated clinical guidance Clinical Support & Subject Matter Expertise Field and respond to AllMed Clinical Questions, ensuring timely and accurate clinical guidance. Serve as a clinical SME for the Core Physician and Pharmacist Appeals Teams, providing support on complex clinical questions and partnering to develop more efficient workflows. Function as a trainer for new hires within the Core Physician Appeals Teams. Audit & Compliance Participate in audit activities as both a researcher and a team oversight lead, ensuring accuracy, readiness, and strong clinical rationale in audit response materials. Support IRE OT/ALJ processes on behalf of VSP physicians, including case review guidance and clinical rationalization. Qualifications MD or DO with active, unrestricted medical license. Strong clinical acumen with experience interpreting complex medical and pharmacy evidence. Prior experience in utilization management, appeals, audit, or clinical operations preferred. Demonstrated ability to lead teams, mentor physicians, and manage performance. Creative problem-solver with a continuous improvement mindset. Strong communication skills and ability to collaborate across multi-disciplinary teams. Use your skills to make an impact Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. Scheduled Weekly Hours 40 Pay Range $270,800 - $378,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. 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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services.