Medical Director - Medicaid Appeals
About The Position
The Medical Director primarily supports Medicaid appeals for the Southeast Region, including Florida, Kentucky, Louisiana, and West Virginia. The position is remote and may be performed from home anywhere in the United States. The role supports Medical Management staff in providing timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints. The Medical Director focuses primarily on medical-necessity appeals, provides clinical expertise and consultation to the Medicaid grievance and appeals team, and chairs or co-chairs Medicaid appeals committee meetings. The position requires an active, unencumbered state medical license and the ability to obtain licensure in Florida, Kentucky, Louisiana, and West Virginia. Candidates must be board certified in an ABMS-recognized specialty and have an M.D. or D.O., with post-graduate direct patient care experience. The role is full-time and eligible for a comprehensive benefits package and a CVS Health bonus, commission, or short-term incentive program, as well as an equity award target.
Requirements
- Five or more years of experience in a health care delivery system, such as clinical practice or the health care industry.
- An active state medical license without encumbrances.
- Ability to obtain medical licensure in Florida, Kentucky, Louisiana, and West Virginia.
- Board certification in an ABMS-recognized specialty.
- M.D. or D.O. with post-graduate direct patient care experience.
Nice To Haves
- Specialty in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.
- Previous experience in Medicaid policy and use of Dynamo Appeals and Grievances (DAG).
- Prior managed care experience in utilization management.
- Prior experience in appeals.
Responsibilities
- Support Medical Management staff in ensuring timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints.
- Focus primarily on member and provider appeals related to medical necessity.
- Provide clinical expertise and consultation to the Medicaid grievance and appeals team.
- Chair or co-chair Medicaid appeals committee meetings.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs.
- Other resources to support colleagues and their families, based on eligibility.
- Eligible for a CVS Health bonus, commission, or short-term incentive program.
- Eligible for an award target in the company equity award program.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
