Medical Director, Medical Affairs

CVS Health•Work At Home-Illinois, IL

2d•$174,070 - $374,920•Remote

About The Position

CVS Health’s Medical Affairs department provides clinical business support across the enterprise, including clinical oversight and mentorship for clinical programs, PBM Clinical Quality activities, consultative support to the P&T process, formulary development, drug information services, pipeline activities, and clinical leadership for internal departments and clients. The Medical Director models clinical integrity, knowledge, cross-functional thinking, and sound decision-making, representing the clinical perspective of prescribers in enterprise decisions and planning. The role reviews clinical cases and coverage requests involving specialty medications, oncology therapies, biologics, and newly marketed drugs. It requires sound medical judgment and the ability to evaluate current literature and evidence-based guidelines, synthesize complex clinical information, assess the strength of evidence, and make objective, consistent, clinically appropriate coverage determinations. Reporting to a Senior Medical Director in Medical Affairs, the role provides clinical support and consultative services across the PBM and may support Account Management for assigned key clients. Much of the work involves medication utilization reviews and medical necessity appeals for commercial clients, Medicare and Medicaid programs, and individual client-requested determinations or appeals. Peer-to-peer conversations may sometimes be required. Directors assigned to one business segment must also develop sufficient proficiency in utilization management programs for other segments to provide evening and weekend coverage. The Medical Director participates in inter-rater reviews and other quality oversight of internal utilization management decisions. The role may oversee part of CVS Health’s clinical programs and commercial client program support, contribute to utilization management criteria and clinical policy reviews or revisions, and conduct clinical investigations and research requested by the Senior Medical Director. Research may range from brief pharmaceutical literature reviews to larger projects involving collaboration with pharmacists within Medical Affairs and other business units. This is a full-time, remote, work-from-home position. The position reports to a Senior Medical Director in the Medical Affairs Department. The listed base pay range is $174,070 to $374,920. The role is also eligible for a CVS Health bonus, commission, or short-term incentive program and an equity award target. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility.

Requirements

ABMS or AOA board certification in Internal Medicine or Family Medicine; current certification in one of these specialties is required.
At least 5 years of clinical experience in direct patient care.
At least 2 years of proven experience in clinical outcomes, with a solid understanding of medical statistics, regulatory agencies, and analytic programs.
Unrestricted medical license in the state where the candidate is located.
Graduate of an accredited medical school and residency program.
Maintain current annual Continuing Medical Education (CME) and remain current in medical and management areas during employment.
Possess an unrestricted active medical license in a U.S. state, territory, commonwealth, or the District of Columbia.

Nice To Haves

Additional subspecialty board certification is strongly preferred.
A combination of five years of management and/or clinical experience in a managed care environment and health administration, including direct patient care and teamwork with professionals at different levels, such as RNs and PharmDs.
Master’s degree in Public Health Administration or an MBA.
UM/QA certification.
Proficiency in MS Office Suite.

Responsibilities

Review clinical cases and coverage requests, including those involving specialty medications, oncology therapies, biologics, and newly marketed drugs.
Evaluate medical literature and evidence-based guidelines and make objective, well-supported, consistent coverage determinations.
Provide clinical support and consultative activities across the PBM, including possible support to Account Management for assigned key clients.
Complete assigned medication utilization reviews and medical necessity appeals for commercial clients, Medicare and Medicaid programs, and individual client requests.
Conduct peer-to-peer conversations when required.
Develop proficiency in utilization management programs across business segments to support evening and weekend coverage when assigned to a particular segment.
Participate in inter-rater review activities and other quality oversight processes for internal utilization management decisions.
Provide oversight for a portion of CVS Health clinical programs and commercial client program support, as assigned.
Contribute to utilization management criteria and clinical policy revisions and reviews.
Conduct special clinical investigations and research as requested, including literature reviews and collaborative projects with pharmacists and other business units.