Medical Director

CVS Health

2d • Remote

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.
This is a remote based (work from home) position. Ideal Candidates will reside in Arizona and have a medical license without encumbrances.
In this role you will:
Support Mercy Care
In the Medical Director role you will provide oversight for medical policy implementation.
You will participate in the development, implementation, and evaluation of clinical / medical programs and expand medical management programs to address member needs across the continuum of care.
You will support the Medical Management staff ensuring timely and consistent responses to members and providers.
As a Medical Director you will focus primarily on overseeing utilization review and quality assurance while being responsible for predetermination reviews and review of claim determinations.
This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls /All Level Appeals / Special Projects and Committee participation when needed.
The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary.
In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Participate in a weekend, holiday and on-call rotation.

Requirements

• Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Active and current medical license without encumbrances
• M.D. or D.O., Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.
• Overnight travel up to 10%
• AZ medical license without encumbrances

Nice To Haves

• Previous UM experience with a Health Plan / Payor.
• Previous UM experience as a Physician Advisor in a Health / Hospital system.
• Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine

Responsibilities

• Provide oversight for medical policy implementation.
• Participate in the development, implementation, and evaluation of clinical / medical programs and expand medical management programs to address member needs across the continuum of care.
• Support the Medical Management staff ensuring timely and consistent responses to members and providers.
• Focus primarily on overseeing utilization review and quality assurance while being responsible for predetermination reviews and review of claim determinations.
• Provide clinical, coding, and reimbursement expertise as well as directing 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 the effective execution of medical services programs by the clinical teams.
• Participate in a weekend, holiday and on-call rotation.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree
• Number of Employees: 5,001-10,000 employees