Medical Director - Medicare Appeals

CVS Health•Work At Home-Connecticut, CT

10d•$174,070 - $374,920•Remote

About The Position

The Medical Director will oversee and support Medicare appeals at Aetna, a CVS Health company. The role is remote and may be performed from anywhere in the United States. Responsibilities include directing daily Part C appeals work, supporting appeal nurses and participating in the Second Look Review process, and providing rotational after-hours and weekend coverage for 24/7 appeals operations. The Medical Director will also monitor and track IRE activity, support Utilization Management strategy, collaborate with Medicare Quality and Compliance, develop enterprise expertise in Medicare policy, educate appeal nurses and territory Utilization Management staff, and help improve appeals team efficiency and clinical consistency. The position requires an MD or DO, an active state medical license without encumbrances, board certification in an ABMS- or AOA-recognized specialty, and at least two years of experience in a health care delivery system or the health care industry. Medicare complaints, grievances, and appeals medical management experience and health plan experience are preferred. The stated pay range is $174,070 to $374,920. The role is eligible for a CVS Health bonus, commission, or short-term incentive program and an equity award target. The full-time benefits package includes medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.

Requirements

At least two years of experience in a health care delivery system, such as clinical practice, or in the health care industry.
Medical degree (MD or DO).
Active state medical license without encumbrances.
Board certification in an ABMS- or AOA-recognized specialty.

Nice To Haves

Medical management experience with Medicare complaints, grievances, and appeals.
Health plan experience.

Responsibilities

Direct daily work on Part C appeals, including provider and member/nonparticipating-provider appeals.
Provide direct support to appeal nurses, including supervision and participation in the Second Look Review (SLR) process.
Provide rotational after-hours and weekend coverage to support 24/7 appeals work.
Monitor and track IRE activity and support Utilization Management strategy.
Collaborate on an ongoing basis with Medicare Quality and Compliance.
Develop subject matter expertise in Medicare policy for the enterprise.
Provide ongoing education about Medicare policy and appeals to appeal nurses and territory Utilization Management staff.
Participate in initiatives to improve appeals team efficiency and clinical consistency.