Medical Director (Great Lakes)

CVS Health; United States; Remote; USD 174,000 - 375,000; Full time

Job summary

CVS Health is seeking a Medical Director who will provide oversight for medical policy implementation and participate in the development of clinical programs. The successful candidate will possess an MD or DO with relevant experience and engage in utilization review while managing quality assurance tasks. This is a remote role focusing on transforming healthcare delivery.

Benefits

Affordable medical plan options

401(k) plan with company matching

Employee stock purchase plan

No-cost wellness programs

Flexible work schedules

Qualifications

• Two or more years of experience in Health Care Delivery.
• Active and current state medical license.
• Board Certification in an ABMS or AOA recognized specialty.

Responsibilities

• Provide oversight for medical policy implementation.
• Focus on utilization review and quality assurance.
• Support Medical Management staff in responses.

Skills

Clinical Practice

Health Care Delivery System

Utilization Review

Education

MD or DO

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.

This is a remote based (work from home) role. Preferred candidates will work Central Time hours and reside in the Great Lakes region.

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.

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 and reviews of claim determinations.
• 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, coding, and reimbursement 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:

*Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

*Active and current state medical license without encumbrances

*M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Preferred Qualifications:

Previous UM experience with a Health Plan / Payor.

Physical Medicine and Rehab ( PM&R)

Acute Rehab and Post Acute Experience

Education:
MD or DO

Pay Range

The typical pay range for this role is:

$174,070.00 - $374,920.00

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.

This is a remote based (work from home) role. Preferred candidates will work Central Time hours and reside in the Great Lakes region.

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.

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 and reviews of claim determinations.
• 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, coding, and reimbursement 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:

*Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

*Active and current state medical license without encumbrances

*M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Preferred Qualifications:

Previous UM experience with a Health Plan / Payor.

Physical Medicine and Rehab ( PM&R)

Acute Rehab and Post Acute Experience

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 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: 07/04/2025

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

About the company

At CVS Health, we share a clear purpose: helping people on their path to better health. Through our health services, plans and community pharmacists, we’re pioneering a bold new approach to total health. Making quality care more affordable, accessible, simple and seamless, to not only help people get well, but help them stay well in body, mind and spirit.

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