Medical Director - MPO (Medical Policy & Operations)

CVS Health•Work At Home-Connecticut, CT

9d•Remote

About The Position

Aetna, a CVS Health company, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company? This is a remote Work at Home position and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy. The Primary Responsibilities of this Medical Director role include transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Medicare and commercial environments; with emphasis on Medicare clinical and payment policy. Knowledge of Aetna and Medicare clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential. This Medical Director may also provide subject matter expertise in clinical and payment policy to support clinical and business direction in these areas. Additional responsibilities may include: The Medical Director - MPO (Medical Policy & Operations) is responsible for providing clinical expertise to promote the delivery of high quality, constituent-focused medical care with a focus on clinical and payment policy. This role involves transactional reviews for appeals, clinical claim reviews, and predetermination of covered benefits in Medicare and commercial environments, with a strong emphasis on Medicare clinical and payment policy. Knowledge of Aetna and Medicare clinical and coding policy, along with experience in appeals, claim review, reimbursement issues, and coding, is preferred, but a willingness to learn is essential. The Medical Director will also serve as a subject matter expert, providing clinical and business direction in these areas. Additional responsibilities include participating in workgroups as a clinical subject matter expert to improve healthcare services, applying expertise to ensure alignment with Aetna policies, using data analysis for quality improvement, acting as an internal consultant and payment policy contributor, and demonstrating the ability to work within and lead diverse teams of health professionals to achieve business objectives. Collaboration with functional areas is also a key aspect of this role. The ideal candidate will have five (5) or more years of experience in a Health Care Delivery System (e.g., Clinical Practice and Health Care Industry). An active and current state medical license without encumbrances is required. Candidates must hold an M.D. or D.O. degree and be Board Certified in an ABMS recognized specialty, with post-graduate direct patient care experience. Preferred qualifications include experience in a health plan/payor setting, familiarity with NCDs, LCDs, and Medicare reviews, foundational skills in Medicine, Health Policy, Coding (HCPCS/CPT), Clinical Policy, Reimbursement, and Health Care Systems, as well as strong written and verbal communication skills. This is a remote, Work-at-Home position, open to candidates located anywhere in the United States. The typical pay range for this role is $174,070.00 - $374,920.00 annually, with the actual salary dependent on factors such as experience, education, and geography. The position is eligible for a CVS Health bonus, commission, or short-term incentive program, as well as an award target in the company’s equity award program. A comprehensive benefits package is offered, including medical, dental, and vision coverage, paid time off, retirement savings options, and wellness programs.

Requirements

Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry
Active and current state medical license without encumbrances
M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience

Nice To Haves

Knowledge of Aetna and Medicare clinical and coding policy
Experience with appeals, claim review, reimbursement issues, and coding
Health plan/payor experience
Experience with NCDs, LCDs, and Medicare reviews
Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems
Strong communication skills both written and verbal
Willingness to learn

Responsibilities

Transactional reviews in support of the appeal process
Clinical claim review process
Predetermination of covered benefits in the Medicare and commercial environments
Provide subject matter expertise in clinical and payment policy to support clinical and business direction
Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services
Apply clinical, coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests
Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services
Be a subject matter expert, internal consultant and payment policy contributor
Demonstrate the ability to work within and lead, as necessary, teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company
Work Collaboratively with the functional areas