Medical Director - Commercial Appeals

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

Job summary

An established industry player in health solutions is seeking a Medical Director to lead medical policy implementation and support clinical teams. This remote position offers a unique opportunity to make a significant impact in health care delivery. You will oversee appeals for denied services, ensuring timely responses to members and providers. The role requires a strong clinical background, with board certification and a focus on Utilization Management. Join a compassionate team dedicated to transforming health care and improving patient outcomes, while enjoying competitive pay and comprehensive benefits.

Benefits

Affordable medical plan options

401(k) plan with matching contributions

Employee stock purchase plan

No-cost wellness programs

Flexible work schedules

Tuition assistance

Paid time off

Dependent care resources

Qualifications

• 2+ years in Health Care Delivery System with clinical practice experience.
• Active state medical license and board certification required.

Responsibilities

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

Skills

Clinical Practice

Utilization Management

Medical Policy Oversight

Case Management

Education

M.D. or D.O. degree

Board Certification in an ABMS or AOA recognized specialty

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.

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
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.

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 review appeal cases for denied medical services.

This 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.

The Medical Director will act as a business and clinical liaison to network providers and facilities if needed, 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. Prior UM (Utilization Management) experience.
3. Active and current state medical license without encumbrances.
4. 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.

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.

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

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.