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.

The Primary Responsibilities of the Medical Director include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. In addition, be a subject matter expert in DRG reviews and ICD-10 code selection .

This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas. In this role you will:

◾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.
◾Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests.

◾Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.
◾ Be a subject matter expert and internal consultant and payment policy contributor subject matter expertise and internal consultant.
◾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.
◾Work Collaboratively with the functional areas.

Required Qualifications

Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Active and current state medical license without encumbrances.
M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience

Preferred Qualifications

Health plan/payor experience.
Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.

Experience with DRG reviews

* Prior hospitalist experience
Strong communication skills both written and verbal.

Education
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.

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: 01/31/2025

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