Medical Director, Behavioral Health

Job not on LinkedIn

🔥 9 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

• Serve as the psychiatric advisor to SIU investigators and leaders, reviewing medical records, coding, and claims involving suspected fraud, waste, abuse, or harmful practice variation • Proactively surface new investigative opportunities while providing clinical support for active investigations and related legal actions • Use clinical expertise, population-level data, advanced analytics, AI, and practice-pattern insights to identify trends, prioritize investigations, and scale clinical impact • Lead cross-functional investigations with clinical, claims, legal, compliance, network, quality, data, and operational partners • Address root causes and implement sustainable solutions • Assess member risk and care variation, document clear findings, and translate complex evidence into recommendations for leaders, customers, and other stakeholders • Prepare well-supported cases for clinical and legal review • Provide testimony in civil or criminal proceedings when required and approved by Legal • Conduct required peer-to-peer reviews • Model Aetna’s Employee Competencies in all interactions

🎯 Requirements

• Five or more years of experience in a health care delivery setting, including clinical practice • Board certification in psychiatry; board eligibility alone is not sufficient • Knowledge of policies and procedures governing payment of health care claims • M.D. or D.O. • Active, unrestricted state medical license(s) • Five years of post-graduate direct patient care experience • At least two years of health care industry experience, including knowledge of CPT and HCPCS coding guidelines (preferred) • Experience applying psychiatric expertise to medical record review and claim-payment determinations under company, state, federal, and industry standards (preferred) • Experience providing psychiatric guidance in the development of business analytics (preferred) • Familiarity with advanced analytics, artificial intelligence, health care technology, population health data, and physician practice-pattern analysis (preferred) • Experience partnering with clinical, investigative, legal, compliance, data science, and operational teams to evaluate complex utilization or claims patterns and drive results (preferred)

🏖️ 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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