Medical Director – Medicaid

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🔥 1 minute ago

🐊 Florida, Kentucky, +1 more states – Remote

🐊 Florida – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – 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 Aetna Better Health of Louisiana and other health plans as needed • Partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers • Perform Utilization Management and medical necessity reviews • Make prior authorization and precertification determinations • Conduct concurrent reviews for inpatient and outpatient services • Perform acute and post-acute care reviews • Conduct peer-to-peer consultations with treating providers • Perform pharmacy reviews and first-level appeal determinations • Collaborate with multidisciplinary clinical and operational teams • Participate in a rotating on-call schedule including weekend and holiday coverage

🎯 Requirements

• Active, unrestricted Louisiana medical license • Ability to be licensed in Florida and Kentucky • M.D. or D.O. degree • Current, active Board Certification in an ABMS- or AOA-recognized specialty • 5+ years of post-residency clinical practice and direct patient care experience • Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics • Prior Utilization Management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity • Medicaid and managed care experience • Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation • Experience using electronic health records and other clinical documentation systems

🏖️ 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