Medical Director – Medical Policy, Operations

Job not on LinkedIn

🔥 14 hours ago

🦌 Connecticut – Remote

🦌 Connecticut – Remote

💵 $174.1k - $374.9k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

👻 Ghost score 0%

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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

• Provide clinical expertise to promote high-quality, constituent-focused medical care, with a focus on clinical and payment policy • Conduct transactional reviews supporting the appeal process • Perform clinical claim reviews • Conduct predetermination of covered benefits in Commercial and Medicare environments • Provide subject matter expertise in clinical and payment policy to support clinical and business direction • Participate in work groups as a clinical subject matter expert to identify and promote opportunities to improve health care quality and efficiency • Apply clinical coding and reimbursement expertise to ensure correct application of Aetna policies and practices to service and payment requests • Use data analysis to identify quality improvement opportunities and positively influence delivery of quality care services • Serve as a subject matter expert, internal consultant and payment policy contributor • Work within and lead diverse teams of health delivery professionals to manage company business objectives • Collaborate with functional areas

🎯 Requirements

• At least one year of experience employed within a health insurance company • Five (5) or more years of experience in a health care delivery system, such as clinical practice, and the health care industry • Active and current state medical license without encumbrances • M.D. or D.O. • Board Certification in an ABMS recognized specialty • Post-graduate direct patient care experience • Foundational baseline skills in medicine, health policy, coding (HCPCS/CPT), clinical policy, reimbursement and health care systems • Strong written and verbal communication skills

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program • Equity award program