Executive Medical Director, Commercial

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🔥 4 minutes ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $227.6k - $490.3k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

⚕️ Healthcare Insurance

🛒 Retail

🧘 Wellness

Healthcare Insurance • Retail • Wellness

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

• Lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality, cost, and outcomes. • Direct the utilization review process and oversee the quality of utilization determinations, including case reviews, peer to peer provider discussions, and appeals. • Ensure compliance with clinical goals through monitoring of care management performance. • Oversee application of medical policies to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of medical management staff. • Recommend changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols. • Develop, implement, and interpret medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments. • Lead clinical staff in the coordination of quality care. • Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities. • Analyze policy/procedure/workflows on case management and utilization management for redesign and efficiency opportunities. • Act as lead clinical liaison to select plan sponsors including reviewing clinical trends, exploring new clinical strategies, handling escalations, and supporting sales and renewal activities as needed. • Support and train SMDs and MDs on such activities. • Identify and advance new affordability initiatives for the Commercial line of business, not limited to medical policy and utilization review activities. • Monitor KPIs and trends to understand value and opportunities and expand Aetna's medical management programs to address member needs across the continuum of care. • Provide clinical support for UM/CM/Appeals complex or escalated cases as appropriate. • Participate in an on‑call rotation, including occasional weekend coverage.

🎯 Requirements

• Five (5) or more years of experience in clinical practice • Five (5) or more years administrative experience in the health care industry or managed care • Demonstrated experience with utilization management, care management, and applicable state and federal regulations • Prior experience leading and developing physician leaders and/or multidisciplinary clinical teams • Demonstrated ability to use data and analytics to inform clinical and business decisions • Proven capability to drive process improvement initiatives and lead change in a complex, matrixed organization • Effective and professional communication skills to engage diverse audiences, including executives, providers, and clients • Ability to manage multiple priorities in a fast‑paced environment • Strategic thinking and planning skills aligned with business objectives • Ability to work in a virtual environment, with periodic business travel (approximately 10%)

🏖️ Benefits

• medical, dental, and vision coverage • paid time off • retirement savings options • wellness programs • other resources, based on eligibility