Executive Medical Director, Medical Affairs

CVS Health•Work At Home-Connecticut, CT

1d•$184,112 - $396,550•Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Quality is part of Aetna’s DNA. We are committed to ensuring that every MD decision reflects sound clinical judgment, consistent application of evidence-based criteria, and an unwavering focus on doing what is best for our members. To strengthen and scale this commitment, Aetna Medical Affairs is establishing a centralized MD Quality function to oversee and ensure the quality of MD decisions across lines of business. This team will ensure rigor, consistency, transparency, and accountability in MD review processes – reinforcing our strong track record while evolving our oversight model to meet the demands of a complex and highly regulated environment. The Executive MD Quality Lead will lead this function, serving as the clinical authority responsible for shaping the future state MD Quality operating model. This role will advance review methodology, performance calibration, and governance to ensure MD decisions remain clinically sound and aligned with enterprise standards and member-first principles.

Requirements

10+ years of clinical experience with progressive leadership in utilization management, medical policy, clinical operations, or quality oversight
Experience leading clinical quality review or MD performance calibration
Deep understanding of clinical coverage determinations, appeals, regulatory standards (e.g., CMS, NCQA), and medical necessity criteria
Experience developing structured training programs to improve performance
Demonstrated ability to influence senior clinical and business leaders in a complex, matrixed organization
Strong analytical skills, including interpretation of variability metrics, IRR results, and audit findings
Executive presence and communications skills, with experience presenting to senior leadership

Nice To Haves

Experience designing/transforming internal clinical quality or audit programs
Direct experience IRR methodology and performance calibration frameworks
Familiarity with multiple lines of business (Commercial, Medicare, Medicaid)
Background in change management or leading enterprise-wide quality improvement initiatives

Responsibilities

Oversee governance of Aetna’s centralized MD Quality function, ensuring alignment with enterprise standards and regulatory requirements
Lead a multidisciplinary team (Clinical and Admin Auditors, Trainers, Data Analyst, and Program Ops Manager) to strengthen audit rigor and consistency in MD reviews
Analyze decision trends and variability to ID high-impact areas for targeted improvement
Evaluate audit methodologies and insights to ensure findings are actionable, defensible, and aligned with priorities
Lead MD Quality forums to set standards and drive transparency and cross-LOB alignment
Prioritize quality improvement and remediation efforts, focusing on highest-impact interventions
Oversee tracking of quality metrics and outcomes to ensure accountability and sustained improvement at individual and team levels
Represent MD Quality in executive forums, providing updates on performance trends, risks, and mitigation strategies
Serve as a trusted clinical advisor, advancing a culture of quality, rigor, and accountability
Own cross-functional partnership with ACS, driving E2E alignment and quality improvement