Medical Director - Medicaid Appeals

CVS Health•New York, NV

2d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health Company, is a national insurer with a unique opportunity to help transform health care. They believe in a more transparent and consumer-focused care system that recognizes physicians for their clinical quality and effective use of health care resources. This role primarily supports the Southeast Region (Florida, Kentucky, Louisiana & West Virginia) and is a remote-based position anywhere in the US. The responsibilities are related to Medicaid Appeals, supporting Medical Management staff in ensuring timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints. The focus is on member and provider appeals related to medical necessity, providing clinical expertise and consultation to the Medicaid grievance and appeals team, and chairing/co-chairing Medicaid appeals committee meetings.

Requirements

Five (5) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
An Active state medical license without encumbrances as well as the ability to obtain FL, KY, LA & WV licensure
Board Certified in ABMS Recognized Specialty
M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Nice To Haves

Family Medicine, Emergency Medicine, Internal Medicine-Pediatrics specialty
Previous experience in Medicaid Policy and the use of Dynamo Appeals and Grievances (DAG)
Prior managed care experience in utilization management
Prior experience in appeals

Responsibilities

Support the Medical Management staff ensuring timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints.
Focus primarily on member and provider appeals related to medical necessity.
Provide clinical expertise and consultation to the Medicaid grievance and appeals team.
Chair/co-chair Medicaid appeals committee meetings.