Medical Director (Medical Policy & Operations)
About The Position
Aetna, a CVS Health company, is hiring a Medical Director for Medical Policy & Operations (MPO). This remote work-at-home role may be located anywhere in the United States. The Medical Director provides clinical expertise to promote high-quality, constituent-focused medical care, with emphasis on clinical and payment policy. The role includes transactional reviews supporting the appeal process, clinical claim review, and predetermination of covered benefits in Commercial and Medicare environments. The Medical Director may also provide subject matter expertise in clinical and payment policy to support clinical and business direction. The role collaborates with diverse health delivery professionals and functional areas to meet business objectives and improve the quality and efficiency of care.
Requirements
- At least one year of experience employed within a health insurance company.
- 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.
- M.D. or D.O. degree.
- Board certification in an ABMS-recognized specialty, including post-graduate direct patient care experience.
Nice To Haves
- Health plan or payor experience.
- Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding; willingness to learn is essential.
- Foundational baseline skills in medicine, health policy, HCPCS/CPT coding, clinical policy, reimbursement, and health care systems.
- Strong written and verbal communication skills.
Responsibilities
- Conduct transactional reviews supporting the appeal process, clinical claim review, and predetermination of covered benefits in Commercial and Medicare environments.
- Participate in work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services.
- Apply clinical coding and reimbursement expertise to ensure correct alignment and application of Aetna policies and practices to service and payment requests.
- Use data analysis proactively to identify quality improvement opportunities and positively influence the effective delivery of quality care services.
- Serve as a subject matter expert, internal consultant, and payment policy contributor.
- Work within and, as needed, lead teams of diverse health delivery professionals to manage company business objectives.
- Collaborate with functional areas.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other resources, based on eligibility.
- Eligibility for a CVS Health bonus, commission, or short-term incentive program.
- An award target in the company’s equity award program.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
