Remote Medical Director: Health Policy & Utilization

CVS Health; Springfield (IL); On-site; USD 174,000 - 375,000; Full time

Job summary

CVS Health is seeking a Medical Director to oversee medical policy implementation and to drive the development, implementation, and evaluation of clinical programs from a remote location. You will support the Medical Management staff and coordinate with network providers to ensure quality, appropriate care across the continuum.

The role requires medical licensure, board certification and substantial clinical leadership experience in health care delivery.

Qualifications

• Five or more years of experience in Health Care Delivery System.
• Active and current medical license without encumbrances.
• M.D. or D.O., Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Responsibilities

• Oversee medical policy implementation.
• Develop, implement, and evaluate clinical programs.
• Support Medical Management staff ensuring timely responses to members and providers.
• Oversee utilization review and quality assurance while reviewing predetermination reviews and claim determinations.
• Lead Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects as needed.
• Provide clinical, coding, and reimbursement expertise and direct case management when necessary.
• Act as lead business and clinical liaison to network providers and facilities.

Skills

Medical license

Board certification

Clinical practice

Education

Medical Doctor or Doctor of Osteopathic Medicine

Job description

CVS Health is seeking a Medical Director to oversee medical policy implementation and to drive the development, implementation, and evaluation of clinical programs from a remote location. You will support the Medical Management staff and coordinate with network providers to ensure quality, appropriate care across the continuum.

The role requires medical licensure, board certification and substantial clinical leadership experience in health care delivery.