Medical Director, Medical Affairs

CVS Health•Work At Home-Illinois, IL

1d•$174,070 - $374,920•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. CVS Health, a Fortune 6 company, has an outstanding opportunity for a Medical Director (Medical Affairs). This is a full-time, remote based, work from home opportunity. The Medical Affairs department provides clinical business support to the entire enterprise and provides clinical oversight and mentorship for CVS Health clinical programs, PBM Clinical Quality activities, consultative support to the P&T process, formulary development, drug information services and pipeline activities, and clinical leadership to various internal departments (e.g., specialty pharmacy services, clinical product development, Enterprise Analytics, Compliance, Legal, Accreditation) and clients. Medical Directors at CVS Health are encouraged to model the highest levels of clinical integrity, knowledge and cross functional thinking, and decision making. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a partner across the enterprise’s decisions and planning. The Medical Director transacts Utilization Management (UM) activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to CVS Health coverage policies. The Medical Director will report to a Senior Medical Director in the Medical Affairs Department and is responsible for clinical support and consultative activities across the PBM. In this role you may provide consultative clinical support to Account Management in support of Key Clients as assigned. Directors will spend a portion of most days completing assigned medication utilization reviews and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate. If specifically assigned to one business segment (i.e., Medicare clients), each director will become sufficiently skilled in various UM programs to support other segments (including commercial and Medicaid) on evening and weekend coverage. Medical Directors will participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions. Each Director may be responsible for providing oversight of a portion of CVS Health's clinical programs and commercial client program support and may share in reviews of utilization management criteria and clinical policy revisions/reviews. Medical Directors may perform a share of special clinical investigations and research as requested by the Senior Medical Director. These projects can include brief reviews of published literature around specific pharmaceutical questions or more in-depth projects requiring collaboration with pharmacists within Medical Affairs and in business units outside of the Department.

Requirements

Family Medicine or Internal Medicine Board Certification REQUIRED
Minimum of 5 years clinical experience in direct patient care
2 or more years proven experience in clinical outcomes, with a solid understanding of medical statistics, regulatory agencies, and analytic programs
Unrestricted license to practice medicine in the state in which the candidate is located
Graduate of an accredited Medical School and Residency Program
Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia
Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employment

Nice To Haves

Combination of five years of management and/or clinical experience in a managed care environment and health administration, including adequate clinical experience in direct patient care and working with professionals at different levels as a teammate (e.g., RNs, PharmDs, etc.)
ABMS or AOA Board Certified in a recognized medical specialty, preferably in a Primary Care field (Internal medicine, Family Medicine)
Master’s Degree in Public Health Administration or MBA preferred
UM/QA certification desired
Proficiency in MS Office Suite

Responsibilities

Transact Utilization Management (UM) activities (prior authorization and appeals)
Respond to prescriber inquiries related to UM transactions and more generally related to CVS Health coverage policies
Provide consultative clinical support to Account Management in support of Key Clients as assigned
Complete assigned medication utilization reviews and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate
Support other segments (including commercial and Medicaid) on evening and weekend coverage if specifically assigned to one business segment (i.e., Medicare clients)
Participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions
Provide oversight of a portion of CVS Health's clinical programs and commercial client program support
Share in reviews of utilization management criteria and clinical policy revisions/reviews
Perform special clinical investigations and research as requested by the Senior Medical Director