Medical Director - Commercial Appeals

Hispanic Alliance for Career Enhancement; Frankfort (KY); On-site; USD 174,000 - 375,000; Full time

Job summary

An established industry player is seeking a Medical Director to oversee medical policy implementation and manage appeals for denied medical services. This remote position offers an opportunity to make a significant impact on health care delivery by ensuring timely responses to members and providers. The ideal candidate will have a strong background in clinical practice, with board certification in an ABMS or AOA recognized specialty. Join a team that values innovation and compassion in health care, and enjoy a comprehensive benefits package designed to support your well-being and professional growth.

Benefits

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings

Tobacco cessation programs

Financial coaching

Tuition assistance

Flexible work schedules

Paid time off

Family leave

Dependent care resources

Qualifications

• 2+ years in Clinical Practice and Health Care Industry.
• Active state medical license without encumbrances.

Responsibilities

• Oversee medical policy implementation and support Medical Management staff.
• Review appeal cases for denied medical services.

Skills

Clinical Practice

Health Care Delivery System

Medical Policy Implementation

Coding Expertise

Reimbursement Expertise

Education

M.D. or D.O.

Board Certification in an ABMS or AOA recognized specialty

Job description

CVS Health Medical Director - Commercial Appeals in Frankfort, Kentucky

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.

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) position.

Preferred candidates will have Internal Medicine or Internal Medicine/Pediatrics (Med/Peds) Board Certification.

In the Medical Director role, you will provide oversight for medical policy implementation and support the Medical Management staff ensuring timely and consistent responses to members and providers.

As a Medical Director, you will focus primarily on reviewing appeal cases for denied medical services, which includes First Level Appeals, Second Level Appeals, Expedited Appeals, Appeal Hearings, Special Projects, and Committee participation when needed.

The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary and act as a business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Required Qualifications

1. Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
2. Active and current state medical license without encumbrances.
3. M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Preferred Qualifications

1. Active and current state medical license in CA without encumbrances and willing to obtain an AZ medical license if needed.
2. Internal Medicine background.

Education

1. M.D. or D.O., Board Certification in an 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 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

We anticipate the application window for this opening will close on: 04/30/2025.

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

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.