Medical Director - FEHBP

CVS Health • Prior Lake, VT

12d • 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. Position Summary Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote-based (work-from-home) role and can be based anywhere in the US. Priority will be given to those residing in Arizona and in the Mountain Time Zone. In this Medical Director role you will provide oversight for medical policy implementation as part of a team dedicated to the Federal Employee Health Benefits Program (FEHBP). You'll participate in the development, implementation, and evaluation of clinical/medical programs, and expand Aetna's medical management programs to address member needs across the continuum of care. You will support the Medical Management staff ensuring timely and consistent responses to members and providers. In addition, you will oversee utilization review, quality assurance, case management, disease management, benefit planning, and fraud investigation. In this role you'll provide clinical expertise and business direction in support of medical and pharmacy management programs through participation in clinical team activities, presentations, and committees. You will act as a lead business and clinical liaison to network providers and facilities, plan sponsors, and related vendors, and will support the effective execution of medical services programs by the clinical teams. You will also be responsible for precertification reviews, appeals, and reviews of claim determinations, providing clinical expertise and judgement. Coding and reimbursement expertise is also appreciated but not required. As a physician leader, you will also maintain your clinical expertise through continuing education and other activities.

Requirements

• 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Active and current state medical license without encumbrances
• M.D. or D.O.
• Current Board Certification in a recognized specialty including post-graduate direct patient care experience.

Nice To Haves

• Health plan/payor experience.
• Electronic medical systems/record experience
• Managed Care experience
• Family Medicine or Internal Medicine Background
• Residing in Arizona or in the Mountain Time Zone

Responsibilities

• Provide oversight for medical policy implementation as part of a team dedicated to the Federal Employee Health Benefits Program (FEHBP).
• Participate in the development, implementation, and evaluation of clinical/medical programs, and expand Aetna's medical management programs to address member needs across the continuum of care.
• Support the Medical Management staff ensuring timely and consistent responses to members and providers.
• Oversee utilization review, quality assurance, case management, disease management, benefit planning, and fraud investigation.
• Provide clinical expertise and business direction in support of medical and pharmacy management programs through participation in clinical team activities, presentations, and committees.
• Act as a lead business and clinical liaison to network providers and facilities, plan sponsors, and related vendors, and will support the effective execution of medical services programs by the clinical teams.
• Responsible for precertification reviews, appeals, and reviews of claim determinations, providing clinical expertise and judgement.
• Maintain your clinical expertise through continuing education and other activities.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
• For more information, visit https://jobs.cvshealth.com/us/en/benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree