Medical Director (Medical Policy & Operations)

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

Job summary

An established industry player is seeking a Medical Director to join their innovative team. This remote position offers the chance to influence the quality of health care delivery across the nation. As a Medical Director in Medical Policy & Operations, you will provide clinical expertise and business direction to enhance medical management programs. Your role will involve collaborating with diverse health delivery professionals to ensure efficient service delivery while utilizing data analysis for continuous improvement. This position not only offers a competitive salary but also a comprehensive benefits package that supports the well-being of its employees.

Benefits

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings and counseling programs

Flexible work schedules

Tuition assistance

Qualifications

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

Responsibilities

• Lead clinical workgroups to enhance health care service quality.
• Apply coding expertise to align with Aetna policies.

Skills

Clinical Expertise

Data Analysis

Communication Skills

Health Care Delivery Knowledge

Education

M.D. or D.O. Degree

Board Certification in an ABMS recognized specialty

Tools

Clinical Coding

Reimbursement Systems

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 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 and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.

This Medical Director provides subject matter expertise to provide clinical support and business direction in these areas.

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.

Primary Responsibilities

1. 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.
2. Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests.
3. Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.
4. Be a subject matter expert and internal consultant and payment policy contributor.
5. 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.
6. Work collaboratively with the functional areas.

Required Qualifications

1. Five (5) 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 recognized specialty including post-graduate direct patient care experience.

Preferred Qualifications

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

Education

1. M.D. or D.O., Board Certification in an ABMS 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.

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.