Medical Director – Medical Policy Ops, DRG

Job not on LinkedIn

🕒 August 6

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $174.1k - $374.9k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

👻 Ghost score 3%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Provide clinical expertise to promote high-quality, constituent-focused medical care, with emphasis on clinical and payment policy • Conduct transactional reviews supporting the appeal process • Perform clinical claim reviews and predeterminations of covered benefits in Commercial and Medicare environments • Provide subject matter expertise in clinical and payment policy to support clinical and business direction • Serve as a subject matter expert in DRG reviews and ICD-10 code selection • Participate in work groups as a clinical subject matter expert to identify opportunities to improve health care quality and efficiency • Apply clinical coding and reimbursement expertise to align service and payment requests with Aetna policies and practices • Use data analysis proactively to identify quality-improvement opportunities and influence effective delivery of quality care services • Act as an internal consultant and payment policy contributor • Work within and lead diverse teams of health delivery professionals to manage company business objectives • Collaborate with functional areas

🎯 Requirements

• Five (5) or more years of experience in a health care delivery system, such as clinical practice, and the health care industry • Active and current state medical license without encumbrances • M.D. or D.O. • Board Certification in an ABMS-recognized specialty • Post-graduate direct patient care experience • Health plan/payor experience preferred • Foundational skills in medicine, health policy, HCPCS/CPT coding, clinical policy, reimbursement, and health care systems preferred • Experience with DRG reviews preferred • Strong written and verbal communication skills preferred

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • Award target in the company’s equity award program • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being, based on eligibility