Medical Director - Florida

CVS Health•Work At Home-Florida, FL

6d•$174,070 - $374,920•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. This is a remote based (work from home) role preferably resides in Florida and preferably has a Florida medical license. 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.

Requirements

Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Active and current state medical license without encumbrances (FL preferred)
M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Nice To Haves

Previous UM experience with a Health Plan / Payor.

Responsibilities

Provide oversight for medical policy implementation.
Participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's 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 / quality assurance and be responsible for predetermination reviews and reviews of claim determinations.
Manage Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.
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.