Medical Director - Florida (3)

CVS Health•Work At Home-Florida, FL

8d•$174,070 - $374,920•Remote

About The Position

This remote, work-from-home Medical Director role is preferably based in Florida, though the physician may be licensed in any U.S. state. At Aetna, a CVS Health company, the Medical Director helps transform health care by supporting transparent, consumer-focused care that recognizes clinical quality and effective use of health care resources. The role provides oversight of medical policy implementation and participates in developing, implementing, and evaluating clinical and medical programs. The Medical Director helps expand medical management programs to address member needs across the continuum of care and supports Medical Management staff in providing timely, consistent responses to members and providers. The position focuses primarily on utilization review and quality assurance, including predetermination reviews and reviews of claim determinations. It 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 Medical Director also serves as a lead business and clinical liaison to network providers and facilities, supporting effective execution of medical services programs by clinical teams. The role includes a base pay range of $174,070 to $374,920. The position is eligible for a CVS Health bonus, commission, or short-term incentive program and an award target in the company’s equity award program. This full-time position is eligible for benefits including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Requirements

Five or more years of experience in a health care delivery system, such as clinical practice, and the health care industry.
Active and current state medical license without encumbrances; Florida licensure 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 utilization management experience with a health plan or payor.
Florida medical license preferred.

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, including prior authorization, precertification, concurrent reviews, peer-to-peer calls, and first-level appeals.
Participate in special projects and committees when 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.