Medical Director (Medical Policy & Operations)

$174,070 - $374,900/Yr

CVS Health - Tallahassee, FL

Full-time - Senior

Remote - Tallahassee, FL

Health and Personal Care Retailers

About the position

Aetna, a CVS Health company, is seeking a Medical Director for Medical Policy & Operations (MPO) to provide clinical expertise and business direction in support of medical management programs. This remote position allows for flexibility as it can be located anywhere in the United States. The Medical Director will play a crucial role in promoting the delivery of high-quality, constituent-focused medical care, with a strong emphasis on clinical and payment policy. In this role, the Medical Director will be responsible for supporting the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits in both the Commercial and Medicare environments. The position requires a subject matter expert who can provide clinical support and business direction in these areas. The Medical Director will participate in work groups to identify and promote opportunities for improving the quality and efficiency of healthcare services. Additionally, the Medical Director will utilize data analysis to identify quality improvement opportunities and influence the effective delivery of quality care services. Collaboration with diverse teams of health delivery professionals is essential to manage the business objectives of the company. The role also involves ensuring alignment and correct application of Aetna policies and practices to service and payment requests, leveraging clinical coding and reimbursement expertise.

Responsibilities

• Provide clinical expertise and business direction in support of medical management programs.
• Support the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits.
• 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.
• Utilize data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.
• Work collaboratively with functional areas and lead diverse teams of health delivery professionals to manage business objectives.

Requirements

• Five (5) or more years of experience in Health Care Delivery System, including 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.

Nice-to-haves

• Health plan/payor experience.
• Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.
• Strong communication skills both written and verbal.

Benefits

• Full range of medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Employee Stock Purchase Plan for eligible employees.
• Fully-paid term life insurance plan for eligible employees.
• Short-term and long-term disability benefits.
• Numerous well-being programs.
• Education assistance and free development courses.
• CVS store discount and discount programs with participating partners.
• Paid Time Off (PTO) or vacation pay, as well as paid holidays throughout the calendar year.