Medical Director - Medicare Appeals

CVS Health • Prior Lake, CT

6d • 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 Aetna, a CVS Health Company, a Fortune 6 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work at home) based anywhere in the US. Responsibilities of this Medical Director role are related to Medicare Appeals:

Requirements

• Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
• Medical License (MD) or (DO)
• An Active state medical license without encumbrances
• Board Certified in ABMS or AOA Recognized Specialty

Nice To Haves

• Medical Management - Medicare Complaints, Grievance & Appeals experience.
• Health Plan Experience Highly Preferred

Responsibilities

• Direct daily work on part C appeals (both provider and member/nonparticipating providers).
• Provide direct support to appeal nurses and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process
• Provide direct support to the Quality Review nurses
• Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work
• IRE monitoring and tracking and Utilization Management Strategy support
• Develop subject matter expertise on Medicare policy for the enterprise
• Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff
• Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency

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