Medical Director - Medicare Appeals
About The Position
Aetna, a CVS Health Company, is seeking a Medical Director to support Medicare Appeals. This is a remote, work-from-home position available anywhere in the United States. The role directs daily Part C appeals work involving providers, members, and nonparticipating providers, and supports appeal nurses through supervision and participation in the Second Look Review process. The Medical Director also contributes to after-hours and weekend coverage on a rotating basis for 24/7 appeals operations, IRE monitoring and tracking, utilization management strategy, and ongoing collaboration with Medicare Quality and Compliance. The position develops enterprise subject matter expertise in Medicare policy, educates appeal nurses and territory Utilization Management staff, and participates in initiatives to improve appeals team efficiency and clinical consistency. Candidates must hold an MD or DO, have an active state medical license without encumbrances, be board certified in an ABMS- or AOA-recognized specialty, and have at least two years of experience in a health care delivery system or the health care industry. Experience with Medicare complaints, grievances, and appeals in medical management is preferred, as is health plan experience. The role offers a base pay range of $174,070 to $374,920, with the actual offer depending on experience, education, geography, and other factors. The position is eligible for a CVS Health bonus, commission, or short-term incentive program, as well as an equity award target. Full-time benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility. The anticipated application window closes October 30, 2026.
Requirements
- At least two years of experience in a health care delivery system, such as clinical practice, or in the health care industry.
- MD or DO degree.
- 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 Part C appeals work for providers, members, and nonparticipating providers.
- Provide direct support to appeal nurses, including supervision and participation in the Second Look Review (SLR) process.
- Provide after-hours and weekend coverage on a rotational basis 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 enterprise subject matter expertise on Medicare policy.
- Provide ongoing education on Medicare policy and appeals to appeal nurses and territory Utilization Management staff.
- Participate in initiatives to improve appeals team efficiency and clinical consistency.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other resources, subject to eligibility.
- Eligibility for a CVS Health bonus, commission, or short-term incentive program.
- An award target in the company 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
