Medical Director – Aetna Duals Center of Excellence

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct concurrent and prior authorization reviews, including peer-to-peer discussions regarding denials.

• Handle appeals within assigned “base plans” and distribute tasks based on similar specialty needs.

• Execute pharmacy reviews.

• Actively participate in and lead medical rounds.

• Assist Medical Management personnel by providing timely and consistent responses to members and providers related to precertification, concurrent review, and appeals.

• Maintain a full-time schedule from Monday to Friday.

⛳️ Requirements

• At least 3-5 years of clinical practice experience.

• A minimum of two (2) years of experience in managed care (Medicare and/or Medicaid).

• Background in utilization management is preferred (Medicare and/or Medicaid experience).

• MD or DO degree is required.

• Board certification in a specialty recognized by ABMS or AOA is mandatory.

• Must possess an active and current state medical license without restrictions.

• Florida medical license or the ability to obtain one is necessary.

• Previous experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System is preferred.

• Must be licensed in or willing to obtain a license in at least one state where we have an Integrated plan.

• Availability to work Eastern Standard Time or Central Standard Time from 8:00 AM to 5:00 PM.

• Willingness to work 1 holiday and 8 weekend days annually.

🏝️ Benefits

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

• Equity award program.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.