Medical Director - Florida (3)

CVS Health•Work At Home-Florida, FL

5d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health company, is seeking a Medical Director to oversee medical policy implementation and participate in the development, implementation, and evaluation of 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. This is a remote, work-from-home position; Florida residency is preferred, and the physician may be licensed anywhere in the United States. The Medical Director primarily oversees utilization review and quality assurance, including predetermination reviews and reviews of claim determinations. The work includes prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, special projects, and committee participation as needed. The physician provides clinical, coding, and reimbursement expertise, directs case management when necessary, and offers clinical expertise and business direction in support of medical management programs. The role also serves as a lead business and clinical liaison to network providers and facilities, supporting the clinical teams’ effective execution of medical services programs. The position is full-time and eligible for a comprehensive benefits package. The stated pay range is $174,070 to $374,920, with the actual offer depending on factors such as experience, education, and geography. The role is also eligible for a CVS Health bonus, commission or short-term incentive program, and an equity award target.

Requirements

Five or more years of experience in a health care delivery system, such as clinical practice, and in the health care industry.
Active and current state medical license without encumbrances.
M.D. or D.O.
Board certification in an ABMS- or AOA-recognized specialty, including post-graduate direct patient care experience.

Nice To Haves

Florida medical license or Florida residency is preferred.
Previous utilization management experience with a health plan or payer.

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.
Handle prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, special projects, and committee participation 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 lead business and clinical liaison to network providers and facilities to support effective execution of medical services programs by clinical teams.