Medical Director

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

📋 Description

• Deliver clinical expertise to enhance high-quality, patient-centered medical care, emphasizing clinical and payment policies.

• Execute transactional reviews to support the appeal process.

• Conduct clinical claim evaluations.

• Perform predetermination assessments of covered benefits in both Commercial and Medicare settings.

• Offer subject matter expertise in clinical and payment policies to aid clinical and business strategies.

• Engage in work groups as a clinical subject matter expert to pinpoint and promote opportunities for improving healthcare quality and efficiency.

• Utilize clinical coding and reimbursement knowledge to ensure the accurate application of Aetna policies and practices in service and payment requests.

• Leverage data analysis to identify opportunities for quality improvement and enhance the effective delivery of quality care services.

• Act as a subject matter expert, internal consultant, and contributor to payment policy.

• Collaborate with and lead diverse teams of healthcare delivery professionals to achieve business objectives.

• Work in partnership with various functional areas.

⛳️ Requirements

• A minimum of five (5) years of experience in a healthcare delivery system, including clinical practice and the healthcare industry.

• A valid and current state medical license without any encumbrances.

• M.D. or D.O. degree.

• Board certification in a specialty recognized by ABMS.

• Experience in direct patient care following postgraduate education.

• Preferred experience in health plans or payor environments.

• Foundational knowledge in medicine, health policy, HCPCS/CPT coding, clinical policy, reimbursement, and healthcare systems is preferred.

• Preferred strong written and verbal communication skills.

• Familiarity with Aetna's clinical and coding policies, along with experience in appeals, claim reviews, reimbursement challenges, and coding is preferred.

• An eagerness to learn.

🏝️ 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.

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