Medical Director - New England Region

CVS Health•New York, VT

2d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health company, is a national insurer seeking a Medical Director to oversee utilization review for health systems in the New England Region. This is a remote, work-from-home position. The preferred candidate resides in Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, or Maine; candidates elsewhere should be able to learn about New England’s hospitals, outpatient networks, and value-based care relationships. The Medical Director primarily oversees utilization review and quality evaluation of inpatient hospitalizations, prior authorizations, and appeals. The role also participates in developing, implementing, and evaluating clinical and medical programs, and in expanding Aetna’s medical management programs to address member needs across the continuum of care. The Medical Director supports Medical Management staff in providing timely, consistent responses to members and providers, including prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, special projects, and committee participation as needed. The role requires an active, unencumbered medical license in a New England state, or the ability to obtain one within a reasonable timeframe. Collaboration and teamwork are central to the New England Medical Director team.

Requirements

Two or more years of experience in a health care delivery system, such as clinical practice, and in the health care industry.
Active and current medical license without encumbrances.
M.D. or D.O. degree.
Active and current board certification in an ABMS- or AOA-recognized specialty, including post-graduate direct patient care experience.
Experience with technology such as Microsoft Outlook and Teams.
A New England state medical license without encumbrances, or the ability to obtain one within a reasonable timeframe.

Nice To Haves

Residence in Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire, or Maine.
Previous utilization management experience with a health plan or payer.
Previous utilization management experience as a Physician Advisor in a health or hospital system.
Board certification in Internal Medicine, Family Medicine, or Emergency Medicine.

Responsibilities

Oversee utilization review for health systems in the New England Region.
Oversee utilization review and quality evaluation of inpatient hospitalizations, prior authorizations, and appeals.
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.
Support prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, special projects, and committee participation as needed.