Medical Director - Medicare Appeals

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

Job summary

An established industry player is seeking a Medical Director to lead non-regulated Medicare appeals. This remote role offers the chance to influence healthcare delivery by supporting appeal processes and enhancing team efficiency. You will provide expertise in Medicare policies and collaborate with compliance teams to ensure high-quality care. The company values innovation and personal connections, providing a supportive environment with robust benefits. If you are passionate about transforming healthcare and have the necessary qualifications, this is an exciting opportunity to make a significant impact.

Benefits

Medical, dental, and vision benefits

401(k) retirement savings plan

Employee Stock Purchase Plan

Fully-paid term life insurance

Short-term and long-term disability benefits

Paid Time Off (PTO)

Paid holidays

CVS store discount

Education assistance

Free development courses

Qualifications

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

Responsibilities

• Support Medicare appeal nurses and provide after-hours coverage.
• Collaborate with Medicare Quality and Compliance teams.

Skills

Medicare policy expertise

Clinical practice experience

Medical management

Collaboration skills

Education

Medical License (MD)

Medical License (DO)

Job description

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

Aetna, a CVS Health Company, a Fortune 6 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 at home) position based anywhere in the US.

Responsibilities of this Medical Director role are related to Part C Medicare Appeals. This position is primary on the non-regulated appeals team, however the expectation is to cross train for regulated appeals.

1. Provide support to Medicare appeal nurses
2. Provide after hours and weekend coverage on a rotational basis to support 72 hour turn around time
3. Collaborative work with Medicare Quality and Compliance on an ongoing basis
4. Provide ongoing education/ subject matter expertise regarding Medicare policy and appeals to the territory Utilization Management staff
5. Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency

Required Qualifications

1. Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
2. Medical License (MD) or (DO)
3. An Active state medical license without encumbrances
4. Board Certified in ABMS Recognized Specialty

Preferred Qualifications

1. Medical Management - Medicare Complaints, Grievance & Appeals experience.
2. Health Plan Experience Highly Preferred

Education

1. Medical License (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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS Health

We anticipate the application window for this opening will close on: 04/11/2025

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