CVS Health - Tallahassee, FL
posted 4 months ago
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.