Medical Director (ABH-WV)

Hispanic Alliance for Career Enhancement; Charleston (WV); Remote; USD 174,000 - 375,000; Full time

Job summary

An established industry player is seeking a Medical Director to elevate healthcare delivery in West Virginia. This role, primarily remote, involves overseeing Utilization Management processes, ensuring timely responses for precertification and concurrent reviews. Ideal candidates will possess a strong background in clinical practice and healthcare systems, alongside a valid medical license. Join a dedicated team committed to transforming health care and enjoy a comprehensive benefits package, including flexible schedules and wellness programs. If you are passionate about making a difference in healthcare, this opportunity is for you.

Benefits

401(k) plan with matching

Employee stock purchase plan

Flexible benefits

Paid time off

Tuition assistance

No-cost wellness programs

Qualifications

• 5+ years in the Healthcare Delivery System with clinical practice experience.
• Active West Virginia medical license and ability to obtain others.

Responsibilities

• Ensure timely responses to members and providers regarding precertification.
• Responsible for Utilization Management including prior authorization.

Skills

Utilization Management

Clinical Practice

Healthcare Delivery System

Electronic Medical Systems

Managed Care

Education

M.D. or D.O.

Board Certification

Job description

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.

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

This Medical Director position is primarily remote, supporting the Aetna West Virginia plan, and is part of a centralized team supporting Medical Management staff.

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

This role is mainly responsible for Utilization Management, including prior authorization, pre-certification, and concurrent review, covering inpatient and outpatient cases, acute and post-acute care, peer-to-peer calls, and first-level appeals.

Required Qualifications:

• Five or more years of experience in the Healthcare Delivery System, e.g., Clinical Practice and Healthcare Industry.
• Active and current West Virginia medical license without encumbrances, with the ability to obtain licenses in Florida, Louisiana, and Kentucky.
• M.D. or D.O., with current and active Board Certification in an ABMS or AOA-recognized specialty, including post-graduate direct patient care experience.
• Preferred specialties: Family Medicine, Emergency Medicine, Internal Medicine-Pediatrics.
• Previous Utilization Management experience at a health plan/insurer or as a Physician Advisor, or experience with an Independent Review Organization, is a plus.

Preferred Qualifications:

• Utilization Management / Review experience within a health plan or payor.
• Experience with electronic medical systems/records.
• Managed Care and Medicaid experience.

Education:

M.D. or D.O., Board Certification in an ABMS or AOA-recognized specialty, with 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 base salary or hourly rates and may vary based on experience, education, location, and other factors. The role is eligible for bonuses, commissions, or incentives, and includes an equity award target.

Our people fuel our future. We are committed to fostering a workplace where every colleague feels valued and belongs.

Benefits:

• Affordable medical options, 401(k) plan with matching, and employee stock purchase plan.
• No-cost wellness programs, tobacco cessation, weight management, counseling, and financial coaching.
• Flexible benefits including paid time off, flexible schedules, family leave, dependent care resources, tuition assistance, retiree medical access, and more.

For more information, visit https://jobs.cvshealth.com/us/en/benefits.

Application deadline: 06/20/2025.

Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.