Medical Director (Great Lakes)

CVS Health

124d • $174,070 - $374,920

About The Position

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. This is a remote based (work from home) role. Preferred candidates will work Central Time hours and reside in the Great Lakes region. 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. In the Medical Director role you will Provide oversight for medical policy implementation. You will 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. As a Medical Director you will Focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews and reviews of claim determinations. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed. The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary. In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities. The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Requirements

• Two (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., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Nice To Haves

• Previous UM experience with a Health Plan / Payor.
• Primary Care - Internal Medicine and Family Medicine.
• Acute Rehab and Post Acute Experience.

Responsibilities

• Provide oversight for medical policy implementation.
• Participate in the development, implementation, and evaluation of clinical / medical programs.
• 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.
• Be responsible for predetermination reviews and reviews of claim determinations.
• Conduct Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.
• Provide clinical, coding, and reimbursement expertise.
• Direct case management when necessary.
• Act as lead business and clinical liaison to network providers and facilities.

Benefits

• Affordable medical plan options.
• 401(k) plan (including matching company contributions).
• Employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Paid time off.
• Flexible work schedules.
• Family leave.
• Dependent care resources.
• Colleague assistance programs.
• Tuition assistance.
• Retiree medical access.

What This Job Offers

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