Exec Dir, Regional MD

CVS Health•Work At Home-Connecticut, CT

4d•$227,630 - $490,280•Hybrid

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. The Executive Medical Director provides clinical and operational leadership across Aetna and CVS enterprise initiatives focused on documentation accuracy, compliance, and medical management performance. The role partners across business units to improve clinical outcomes, support risk analysis activities, lead audit-related work, and strengthen key external relationships. This leader also oversees medical management programs and policies, leads the territory Senior Medical Directors, and drives execution against strategic and operational priorities.

Requirements

3+ years of leadership experience in the Medicare line of business, or a related role
3+ years of clinical practice experience
3+ years of leadership experience in managed care
M.D. or D.O. with board certification in a recognized specialty and post-graduate direct patient care experience
Active, unrestricted state medical license

Nice To Haves

Demonstrated leadership experience in clinical operations, medical management, and utilization management

Responsibilities

Leads, develops, and directs clinical and non-clinical activities that improve health care quality, cost, and outcomes
Directs the utilization review process and oversees the quality of utilization determinations
Ensures compliance with clinical goals by monitoring care management performance
Oversees unit medical policies to support appropriate, cost-effective care and day-to-day management of medical management staff
Recommends changes to managed care programs, review guidelines, and clinical criteria based on deep knowledge of care delivery, utilization, reimbursement, and treatment protocols
Develops, implements, and interprets medical policy, including medical necessity criteria, clinical practice guidelines, and new technology assessments
Leads clinical staff (territory senior medical directors and transactional medical directors) in coordinating quality care and provides clinical expertise and business direction to support medical management programs
Serves as the lead business and clinical liaison to network providers and facilities to support effective execution of medical services programs
Expands Aetna medical management programs to address member needs across the continuum of care
Reviews and handles cases as needed
Provides weekend on-call coverage as needed