Medical Director (ABH-WV)

CVS Health; Charleston (WV); Remote; USD 174,000 - 375,000; Full time

Job summary

A leading health solutions company is seeking a Medical Director to oversee Utilization Management for Aetna Better Health of West Virginia. This remote position requires a strong background in healthcare delivery systems and a valid medical license. The role involves managing precertification and concurrent review processes, ensuring quality care for members. Join a dedicated team focused on transforming healthcare and enjoy comprehensive benefits, including flexible schedules and wellness programs.

Benefits

401(k)

Employee stock purchase plans

Wellness programs

Paid time off

Flexible schedules

Tuition assistance

Qualifications

• Five or more years of experience in Healthcare Delivery Systems.
• Active West Virginia medical license, ability to obtain licenses in FL, LA, KY.
• Prior Utilization Management experience is a plus.

Responsibilities

• Ensure timely responses to members and providers regarding precertification.
• Responsible for Utilization Management including prior authorization.
• Support Aetna Better Health of West Virginia and the Southeast Region.

Skills

Healthcare Delivery Systems

Utilization Management

Clinical Practice

Education

M.D. or D.O.

Board Certification in ABMS or AOA recognized specialty

Job description

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At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels, and more than 300,000 purpose-driven colleagues – caring for people where, when, and how they choose in a way that is uniquely more connected, more convenient, and more compassionate. And we do it all with heart, each and every day.

Position Summary

Ready to take your Medical Director skills to the next level with a Fortune 6 company? Check out this opportunity with Aetna, a CVS Health company!

Aetna operates Medicaid managed care plans in multiple states: Arizona, California, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Pennsylvania, Texas, Virginia, West Virginia, and Oklahoma.

This role supports the Aetna Better Health of West Virginia primarily, and the Southeast Region (FL, KY, LA).

This Medical Director will be a "Work from Home" position primarily supporting the Aetna West Virginia plan; but part of a centralized team that supports the Medical Management staff.

The Medical Director will ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal requests.

This position is primarily responsible for Utilization Management, including prior authorization and pre-certification as well as concurrent review. Cases could focus on inpatient or outpatient, acute and post-acute, peer-to-peer calls, and first-level appeals.

Minimum Qualifications

• Five or more years of experience in Healthcare Delivery Systems, e.g., Clinical Practice and Healthcare Industry.
• Active and current West Virginia medical license without encumbrances, with ability to obtain licenses in Florida, Louisiana, and Kentucky.
• M.D. or D.O., Board Certification in ABMS or AOA recognized specialty; including post-graduate direct patient care experience.
• Family Medicine, Emergency Medicine, Internal Medicine-Pediatrics preferred.
• Prior Utilization Management experience working at a Health Plan/Insurer or as a Physician Advisor or with an Independent Review Organization is a plus.

Preferred Qualifications

• Utilization Management / Review experience in health plans/payors.
• Experience with electronic medical systems/records.
• Managed Care experience.
• Medicaid experience.

Education

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

Pay Range

The Typical Pay Range for This Role is $174,070.00 - $374,920.00

This range reflects the base salary or hourly rate, with actual offers depending on experience, education, location, and other factors. The role is eligible for bonuses, incentives, and equity awards.

Benefits

Our comprehensive benefits include medical plans, 401(k), employee stock purchase plans, wellness programs, paid time off, flexible schedules, family leave, dependent care resources, tuition assistance, retiree medical, and more. For details, visit https://jobs.cvshealth.com/us/en/benefits

Application deadline: 06/20/2025.

CVS Health is committed to diversity and considers qualified applicants with arrest or conviction records in accordance with laws.

Seniority level

• Director

Employment type

• Full-time

Job function

• Health Care Provider

Industries

• Hospitals and Health Care