Medical Director - Capstone Market

CVS Health; Harrisburg (Dauphin County); Remote; USD 174.000 - 375.000; Vollzeit

Zusammenfassung

CVS Health's Aetna division seeks a Medical Director to oversee medical policy and contribute to clinical programs across the continuum of care. This remote role supports Medical Management staff and focuses on utilization review, QA, and predetermination reviews.

You will provide clinical expertise, participate in committee work, and liaise with network providers to ensure high-quality, compliant medical services.

Qualifikationen

• MD or DO and board-certified in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.
• Active and current state medical license.

Aufgaben

• Oversee medical policy implementation.
• Develop, implement and evaluate clinical programs across the continuum of care.
• Support Medical Management staff ensuring timely responses to members and providers.
• Oversee utilization review, quality assurance and predetermination reviews.
• Lead business/clinical liaison to network providers for program execution.

Kenntnisse

MD/DO credential

Board Certification

Medical license

Ausbildung

MD or DO

Jobbeschreibung

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.

This is a remote based (work from home) role preferably resides in PA/DE/WV and have an active and current US medical license without encumbrances.

In the Medical Director role you will provide oversight for medical policy implementation.

You will participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.

You will support the Medical Management staff ensuring timely and consistent responses to members and providers.

As a Medical Director you will focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews.

This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.

The Medical Director will provide clinical expertise as well as directing case management when necessary.

In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.

The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Required Qualifications

• M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.
• Active and current state medical license

Preferred Qualifications

• Active and current state medical license in either PA/WV/DE state without encumbrances
• Previous UM experience with a Health Plan/Payor.

Education

MD or DO

Pay Range

The Typical Pay Range For This Role Is

$174,070.00 - $374,920.00

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great Benefits For Great People

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 11/10/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.