Medical Director - Midland States

CVS Health • Work At Home-Iowa, IL

1d • $174,070 - $374,920 • Remote

About The Position

Aetna, a CVS Health company, is seeking a Medical Director to provide oversight for medical policy implementation and help develop, implement, and evaluate clinical and medical programs. The role supports the expansion of medical management programs to address member needs across the continuum of care and helps ensure timely, consistent responses to members and providers.

The Medical Director primarily oversees utilization review and quality assurance and performs predetermination reviews and reviews of claim determinations. Work includes prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, special projects, and committee participation as needed. The role also provides clinical, coding, and reimbursement expertise and directs case management when necessary.

The Medical Director provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. The role serves as the lead business and clinical liaison to network providers and facilities, supporting the effective execution of medical services programs by clinical teams.

This is a remote, work-from-home position. Ideal candidates reside in Illinois, Missouri, Minnesota, or Wisconsin and hold an unencumbered medical license in one of those states.

Requirements

• At least five years of experience in a health care delivery system, such as clinical practice, and in the health care industry.
• Active, current medical license without encumbrances.
• M.D. or D.O. degree.
• Active, current board certification in an ABMS- or AOA-recognized specialty, including postgraduate direct patient care experience.

Nice To Haves

• Previous utilization management experience with a health plan, payer, or as a physician advisor in a health care system.
• Board certification in Internal Medicine, Family Medicine, Emergency Medicine, Med/Peds, or General Surgery.

Responsibilities

• Provide oversight for medical policy implementation.
• Participate in the development, implementation, and evaluation of clinical and medical programs.
• Expand medical management programs to address member needs across the continuum of care.
• Support Medical Management staff in providing timely and consistent responses to members and providers.
• Oversee utilization review and quality assurance.
• Conduct predetermination reviews and reviews of claim determinations, including prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, and first-level appeals.
• Participate in special projects and committees as needed.
• Provide clinical, coding, and reimbursement expertise.
• Direct case management when necessary.
• Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
• Act as the lead business and clinical liaison to network providers and facilities to support effective execution of medical services programs by clinical teams.

Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting physical, emotional, and financial well-being, based on eligibility
• Eligibility for a CVS Health bonus, commission, or short-term incentive program
• An award target in the company equity award program

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree