Medical Director – Aetna Duals Center of Excellence

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🔥 12 minutes ago

🇺🇸 United States – Remote

💵 $174.1k - $374.9k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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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

• Perform concurrent and prior authorization reviews with peer-to-peer coverage of denials • Perform appeals in assigned “base plans” and round robin based on same or similar specialty needs • Perform pharmacy reviews • Participate in and lead rounds • Support Medical Management staff with timely and consistent responses to members and providers regarding precertification, concurrent review, and appeal requests • Work a full-time Monday-to-Friday schedule

🎯 Requirements

• Minimum 3-5 years of clinical practice experience • Two (2) + years of experience in managed care (Medicare and/or Medicaid) • Experience with utilization management (preferred Medicare and/or Medicaid) • MD or DO • Board certification in an ABMS or AOA recognized specialty is required • Active and current state medical license without encumbrances is required • Florida license or ability to obtain • Previous experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System preferred • Licensed in or willing to obtain license in at least one state where we have an Integrated plan • Ability to work Eastern Standard Time or Central Standard Time from 8:00 AM to 5:00 PM • Availability to work 1 holiday and 8 weekend days each year

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program • 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

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