Medical Director – Medicaid Appeals

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🔥 0 minutes ago

🦌 Connecticut, Idaho, +2 more states – Remote

🦌 Connecticut – Remote 🥔 Idaho – Remote ❄️ Minnesota – Remote 🤠 Texas – 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

• Support Medical Management staff with timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints • Focus on member and provider appeals related to medical necessity • Provide clinical expertise and consultation to the Medicaid grievance and appeals team • Chair or co-chair Medicaid appeals committee meetings • Primarily support the Southeast Region, including Florida, Kentucky, Louisiana, and West Virginia

🎯 Requirements

• Five (5) or more years of experience in a health care delivery system, such as clinical practice or the health care industry • Active state medical license without encumbrances • Ability to obtain Florida, Kentucky, Louisiana, and West Virginia licensure • Board certified in an ABMS-recognized specialty • M.D. or D.O. • Board certification in an ABMS- or AOA-recognized specialty • Post-graduate direct patient care experience • Preferred: Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics specialty • Preferred: Previous experience in Medicaid policy and Dynamo Appeals and Grievances (DAG) • Preferred: Prior managed care experience in utilization management • Preferred: Prior experience in appeals

🏖️ 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