Medical Director - Clinical Strategy & Utilization

CVS Health; Arizona; Hybrid; USD 174,000 - 375,000; Full time

Job summary

CVS Health is seeking a Medical Director on the Aetna One Advocate team to lead utilization management, predetermination reviews, and clinical program development. You will guide decisions with a multidisciplinary group of physicians and participate in external engagements with plan sponsors.

You'll provide clinical oversight for medical policy implementation, oversee case management, and contribute to expanding medical management initiatives to improve member outcomes.

Qualifications

• MD/DO required with ABMS board certification in an appropriate specialty.
• Experience in utilization management or managed care is not required as training is provided.
• Strong public speaking and stakeholder communication skills are essential.
• Collaborative mindset and ability to work in a fast-moving clinical team.

Responsibilities

• Lead utilization management, including predetermination and UM reviews.
• Apply clinical expertise to support accurate, consistent decisions.
• Participate in the development, implementation, and evaluation of clinical/medical programs.
• Help expand medical management programs to better address member needs across the continuum of care.
• Support Medical Management staff in delivering timely, consistent responses to members and providers.
• Direct case management efforts and oversee utilization review/quality assurance.
• Provide clinical and business direction for medical management programs.
• Serve as lead clinical and business liaison to network providers and facilities.

Skills

Clinical leadership

Public speaking

Team collaboration

Education

MD/DO

Board certification (Neurosurgery/Orthopedic/General/PM&R)

Job description

CVS Health is seeking a Medical Director on the Aetna One Advocate team to lead utilization management, predetermination reviews, and clinical program development. You will guide decisions with a multidisciplinary group of physicians and participate in external engagements with plan sponsors.

You'll provide clinical oversight for medical policy implementation, oversee case management, and contribute to expanding medical management initiatives to improve member outcomes.