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.Aetna, a CVS Health 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 from home) full-time position and can be based anywhere in the United States.** The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse.- Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
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- Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse.
- Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions.
- Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.
- Maintains open communication with constituents within the company.
- Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
- Researches and prepares cases for clinical and legal review
- Documents all appropriate information related to medical record review determinations.
- Represents Aetna as a witness in court actions, as required, and as approved by Legal. The expectation is that the BH Medical Director will have a high level of knowledge when providing testimony during civil and criminal proceedings. The BH Medical Director must be able to travel, as needed, and provide detailed testimony based upon the BH Medical Director's documentation.
- Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review - Exhibits behaviors outlined in Employee Competencies.Required Qualifications
- Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice)
- Board Certified Psychiatrist not "Board Eligible" - Active and Unencumbered license to practice medicine
- Knowledge of pertinent policies and procedures related to claims payment of healthcare related services.Preferred Qualifications
- 2 years' experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles
- Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
- Psychiatric experience in providing clinical guidance and input in the business analytic building process.
- Child and Adolescent PsychiatristEducation - Active and current state medical license(s) without encumbrances - M.D. or D.O., Board Certification in psychiatry, including 5 years of 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.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 peopleWe 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.