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. Medical Directors are responsible for reviewing a broad range of clinical cases and coverage requests, including specialty medications, oncology therapies, biologics, and newly marketed drugs. Success in this role requires a strong clinical foundation, sound medical judgment, and the ability to efficiently identify, evaluate, and apply current medical literature and evidence-based guidelines. Medical Directors must be able to synthesize complex clinical information, assess the strength of available evidence, and make objective, well-supported coverage determinations that are clinically appropriate, consistent, and evidence based. 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. Peer to peer conversations may be required at times. 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 is REQUIRED.
Minimum of 5 years of 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

Additional subspecialty board certification is strongly preferred.
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 teammates (e.g., RNs, PharmDs, etc.).
ABMS or AOA Board Certified in a Internal medicine or Family Medicine.
Master’s Degree in Public Health Administration or MBA preferred.
UM/QA certification desired.
Proficiency in MS Office Suite.

Responsibilities

Reviewing a broad range of clinical cases and coverage requests, including specialty medications, oncology therapies, biologics, and newly marketed drugs.
Synthesizing complex clinical information, assessing the strength of available evidence, and making objective, well-supported coverage determinations that are clinically appropriate, consistent, and evidence based.
Providing clinical support and consultative activities across the PBM.
Providing consultative clinical support to Account Management in support of Key Clients as assigned.
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.
Participating in inter-rater review activities and other quality oversight processes for internal Director UM decisions.
Providing oversight of a portion of CVS Health's clinical programs and commercial client program support.
Sharing in reviews of utilization management criteria and clinical policy revisions/reviews.
Performing special clinical investigations and research as requested by the Senior Medical Director.