Medical Director (Medical Policy & Operations)

This is a remote Work at Home position and can be located anywhere in the United States.

In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.

This Medical Director provides subject matter expertise to provide clinical support and business direction in these areas.

Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.

The Primary Responsibilities of the Medical Director include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. In addition, be a subject matter expert in women's health, infertility and genetic policies and reviews.

This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas. In this role you will:

◾Participate on 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 alignment and correct application of Aetna policies and practices to service and payment requests.

◾Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.
◾ Be a subject matter expert and internal consultant and payment policy contributor subject matter expertise and internal consultant.
◾Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company.
◾Work Collaboratively with the functional areas.

Required Qualifications

Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Active and current state medical license without encumbrances.
M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience

Preferred Qualifications

Health plan/payor experience.
Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.

Board Certification in OB/GYN
Strong communication skills both written and verbal.

Education
M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience

Pay Range

The typical pay range for this role is:

$174,070.00 - $374,900.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company's equity award program.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 04/29/2024

CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.

You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.

CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.