Medical Director (Medical Policy & Operations)

CVS Health; Hartford (CT); Remote; USD 174,000 - 375,000; Full time

Benefits offered by this job

Comprehensive benefits package

Bonus/commission eligibility

Equity award program

Job summary

CVS Health is seeking a Medical Director MPO (Medical Policy & Operations) to provide clinical leadership from a remote position anywhere in the United States. The role focuses on policy, clinical review, and payment decisions to support high-quality care for Commercial and Medicare populations.

Responsibilities include handling appeals, claim reviews, and predetermination of benefits, with strong emphasis on coding policy, reimbursement, and performance analytics. Aetna experience is preferred.

Qualifications

• MD or DO and active state medical license
• 5+ years in Health Care Delivery System (clinical practice and health care industry)
• 1+ year experience in a health insurance company
• Foundational knowledge in medical policy, coding (HCPCS/CPT) and reimbursements

Responsibilities

• Provide clinical expertise to promote high-quality, constituent-focused medical care and policy
• Review transactions to support appeals and predetermination of benefits in Commercial and Medicare environments
• Lead or participate in cross-functional work groups to improve care quality and efficiency
• Apply clinical coding and reimbursement knowledge to ensure alignment with Aetna policies
• Collaborate with health delivery professionals to meet business objectives

Skills

Clinical experience

Health insurance knowledge

Strong communication

Team collaboration

Education

MD or DO

Board Certification in ABMS specialty

Job description

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.

*** A Doctorate in Medicine (MD) or Osteopathic Medicine (DO) is required for this role. ***

Position Summary

Aetna, a CVS Health company, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company? This is a remote Work at Home position and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.

The Primary Responsibilities of this Medical Director role include transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Commercial and Medicare environments.

Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential. This Medical Director may also provide subject matter expertise in clinical and payment policy to support clinical and business direction in these areas.

Additional responsibilities may include

• Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services.
• Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests.
• Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.
• Be a subject matter expert, internal consultant and payment policy contributor.
• Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company.
• Work Collaboratively with the functional areas.

Required Qualifications

• At least one year of experience employed within a health insurance company
• Five (5) 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 recognized specialty including post-graduate direct patient care experience

Preferred Qualifications

• Health plan/payor experience.
• Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.
• Strong communication skills both written and verbal.

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.
• Medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• 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.

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: 11/14/2026

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