Senior Medical Director Precertification Team

CVS Health

10d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: Aetna, a CVS Health Company, has an outstanding opportunity for a Senior Medical Director to provide end-to-end clinical and operational leadership for Medicare and other activities, ensuring the highest standards of quality, compliance, and efficiency across the continuum of services. This leader is responsible for developing, training, and managing the Precertification Team, ensuring compliance, efficiency, and evidence-based decision making, driving process improvement, and fostering a collaborative team culture. This senior level MD serves as a key liaison between clinical and non-clinical stakeholders to ensure effective operations, communication, and strategic alignment. This role provides strategic leadership and oversight for clinical operations by developing and implementing clinical policies and protocols, ensuring high-quality patient care, overseeing clinical functions, promoting evidence-based practices, and collaborating with cross-functional leaders to improve clinical outcomes and patient safety. They apply medical expertise, leadership skills, and knowledge of industry standards to drive clinical excellence, optimize resources, and contribute to the overall success of the organization's clinical operations.

Requirements

• MD or DO with active, unrestricted license and board certification in an ABMS or AOA recognized specialty
• Minimum 5 years of direct patient care in a clinical setting
• Minimum 5 years in utilization management, precertification, or related roles
• Deep expertise in Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references
• Proven ability to interpret and apply Medicare guidelines to complex case review and decision-making
• Advanced knowledge of medical coding standards, compliance requirements, and oversight of coding practices
• Demonstrated leadership in managing teams, driving process improvement, and ensuring regulatory compliance
• Successful track record guiding teams through Medicare audits and maintaining audit readiness
• Strong interpersonal, communication, and cross-functional stakeholder management skills
• Commitment to developing talent and fostering an inclusive, high-performing team culture

Nice To Haves

• Experience working in large, matrixed healthcare organizations
• Familiarity with data analytics and performance management tools
• Certified Professional Coder (CPC) credential or equivalent certification
• Proficiency with multiple documentation platforms for acute utilization management and appeals
• Prior leadership roles with increasing responsibility

Responsibilities

• Provides strategic direction, professional oversight, and leadership throughout the precert process and other clinical operations.
• Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.
• Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.
• Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.
• Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.
• Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.
• Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.
• Leads teams through Medicare audits and on-going audit readiness.
• Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.
• Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.
• Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.
• Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.
• Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree
• Number of Employees: 5,001-10,000 employees