Medical Director, Medical Affairs

CVS Health•Work At Home-Illinois, IL

2d•$174,070 - $374,920•Remote

About The Position

CVS Health is seeking a full-time, remote Medical Director in its Medical Affairs department. Medical Affairs 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. Medical Directors model clinical integrity, knowledge, cross-functional thinking, and sound decision-making. They represent the prescriber’s clinical decision-making and professional perspective in enterprise decisions and planning. The role reviews a broad range of clinical cases and coverage requests, including specialty medications, oncology therapies, biologics, and newly marketed drugs, and makes objective, well-supported, evidence-based coverage determinations. The Medical Director reports to a Senior Medical Director in Medical Affairs and provides clinical support and consultation across the PBM, potentially supporting Account Management for assigned key clients. The position includes medication utilization reviews and medical necessity appeals for commercial, Medicare, Medicaid, and other client programs. Peer-to-peer conversations may be required. Directors may also participate in quality oversight, review utilization management criteria and clinical policies, oversee portions of clinical programs and client support, and conduct clinical investigations or research at the request of the Senior Medical Director.

Requirements

Board certification in Family Medicine or Internal Medicine is required.
At least 5 years of clinical experience in direct patient care.
At least 2 years of proven clinical outcomes experience, with a solid understanding of medical statistics, regulatory agencies, and analytic programs.
Unrestricted license to practice medicine in the state where the candidate is located.
Graduate of an accredited medical school and residency program.
Maintain required annual Continuing Medical Education (CME) and remain current in medical and management areas during employment.
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.
Combination of five years of management and/or clinical experience in managed care and health administration, including direct patient care and experience working with professionals at different levels as teammates.
ABMS or AOA board certification in Internal Medicine or Family Medicine.
Master’s degree in Public Health Administration or MBA.
UM/QA certification.
Proficiency in MS Office Suite.

Responsibilities

Review clinical cases and coverage requests, including specialty medications, oncology therapies, biologics, and newly marketed drugs.
Evaluate current medical literature and evidence-based guidelines; synthesize complex clinical information and assess evidence strength to make clinically appropriate, consistent, and evidence-based coverage determinations.
Provide clinical support and consultative activities across the PBM, including support to Account Management for assigned key clients.
Complete assigned medication utilization reviews and medical necessity appeals for commercial, Medicare, Medicaid, and other client-requested coverage determinations or appeals.
Conduct peer-to-peer conversations when required.
Support other business segments, including commercial and Medicaid, during evening and weekend coverage when assigned to a particular segment.
Participate in inter-rater review activities and quality oversight of internal utilization management decisions.
Provide oversight for assigned clinical programs and commercial client program support.
Participate in reviews of utilization management criteria and clinical policy revisions or reviews.
Conduct special clinical investigations and research, including literature reviews and collaborative projects with pharmacists in Medical Affairs and other business units.