Remote Medical Policy & DRG Director

LeadingAge Connecticut; Connecticut; Hybrid; USD 174,000 - 375,000; Full time

Job summary

CVS Health is seeking a Medical Director MPO (Medical Policy & Operations) to promote high-quality, patient-centered care across Commercial and Medicare. This fully remote role can be located anywhere in the United States and will emphasize policy and clinical excellence.

The role involves transactional reviews for appeals, medical claim assessments, and predetermination of covered benefits, with expertise in DRG reviews and ICD-10 coding. Strong leadership and communication are essential.

Qualifications

• Five or more years in Health Care Delivery System (clinical practice or health care industry).
• Active and current state medical license without encumbrances.
• MD or DO with ABMS board certification and direct patient care experience.

Responsibilities

• Provide clinical expertise to promote high quality patient care and policy alignment.
• Oversee transactional reviews for appeals, claims, and predetermination of benefits.
• Support clinical and payment policy with data analysis to improve care quality and efficiency.
• Lead cross-functional teams and advise on DRG reviews and ICD-10 coding.

Skills

Clinical practice

Health policy

Coding: HCPCS/CPT

Communication skills

Data analysis

Education

MD or DO

Tools

DRG reviews

Job description

CVS Health is seeking a Medical Director MPO (Medical Policy & Operations) to promote high-quality, patient-centered care across Commercial and Medicare. This fully remote role can be located anywhere in the United States and will emphasize policy and clinical excellence.

The role involves transactional reviews for appeals, medical claim assessments, and predetermination of covered benefits, with expertise in DRG reviews and ICD-10 coding. Strong leadership and communication are essential.