Medical Director-Medicaid (ABH VA)
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. This is a full-time, fully remote role. You can work from anywhere in the United States. Join Aetna, a CVS Health company, and make a meaningful impact on the health and well-being of Medicaid members across the country. Aetna operates Medicaid managed care plans in Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia. We are seeking a Medical Director to join our centralized Medical Management team. This work-from-home position will primarily support Aetna Better Health of Virginia, while also providing support across the Northeast Region (Maryland, New Jersey, New York, and Pennsylvania) and other health plans as needed. In this role, you will partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers. Key responsibilities include: Utilization Management and medical necessity reviews Prior authorization and precertification determinations Concurrent review for inpatient and outpatient services Acute and post-acute care reviews Peer-to-peer consultations with treating providers Pharmacy reviews and first-level appeal determinations Collaboration with multidisciplinary clinical and operational teams The Medical Director also participates in a rotating on-call schedule that includes weekend and holiday coverage. If you are a physician leader who is passionate about improving quality, access, and outcomes for Medicaid populations, we would love to connect with you.
Requirements
- M.D. or D.O. degree with current, active Board Certification in an ABMS- or AOA-recognized specialty.
- 5+ years of post-residency clinical practice and direct patient care experience.
- Active, unrestricted Virginia medical license.
- Ability to obtain and maintain medical licenses in Maryland, New Jersey, New York and Pennsylvania.
Nice To Haves
- Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.
- Prior Utilization Management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity.
- Medicaid and managed care experience.
- Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation.
- Experience using electronic health records and other clinical documentation systems.
Responsibilities
- Utilization Management and medical necessity reviews
- Prior authorization and precertification determinations
- Concurrent review for inpatient and outpatient services
- Acute and post-acute care reviews
- Peer-to-peer consultations with treating providers
- Pharmacy reviews and first-level appeal determinations
- Collaboration with multidisciplinary clinical and operational teams
- Participates in a rotating on-call schedule that includes weekend and holiday coverage.
Benefits
- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
