Medical Director-Medicaid (ABH-WV)

CVS Health

5d • 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: Ready to take your Medical Director skills to the next level with a Fortune 6 company? Checkout this opportunity with Aetna, a CVS Health company! Aetna operates Medicaid managed care plans in multiple states: Arizona, California, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia and West Virginia. This supports the Aetna Better Health of West Virginia primarily This Medical Director role will be a "Work from Home" position primarily supporting the Aetna West Virginia plan, and the Southeast Region (FL, KY and LA). The Medical Director is part of a centralized team that supports the Medical Management staff and may support other health plans as needed. The Medical Director will ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal requests. This position is primarily responsible for Utilization Management, including prior authorization and precertification as well as concurrent review. Cases could focus on inpatient or outpatient, acute and post-acute as well as peer to peer calls and first level appeals. The Medical Director participates in a rotating on call schedule to provide weekend and holiday coverage.

Requirements

• Five or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Active and current West Virginia state medical license without encumbrances as well as the ability to obtain Florida, Louisiana and Kentucky licenses.
• M.D. or D.O., Current and Active Board Certification in ABMS or AOA recognized specialty; including post-graduate direct patient care experience
• Family Medicine, Emergency Medicine, Internal Medicine-Pediatrics Specialty Preferred.

Nice To Haves

• Health plan/payor Utilization Management / Review experience.
• Electronic medical systems/record experience.
• Managed Care experience.
• Medicaid experience.

Responsibilities

• ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal requests.
• primarily responsible for Utilization Management, including prior authorization and precertification as well as concurrent review.
• Cases could focus on inpatient or outpatient, acute and post-acute as well as peer to peer calls and first level appeals.
• participates in a rotating on call schedule to provide weekend and holiday coverage.

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.

What This Job Offers

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