Medical Director, Behavioral Health

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

📋 Description

• Act as the psychiatric consultant for SIU investigators and leadership, examining medical records, coding, and claims related to suspected fraud, waste, abuse, or detrimental practice variations.

• Actively identify new investigative opportunities while offering clinical support for ongoing investigations and associated legal actions.

• Leverage clinical knowledge, population-level data, advanced analytics, AI, and practice-pattern insights to detect trends, prioritize investigations, and enhance clinical impact.

• Oversee multidisciplinary investigations in collaboration with clinical, claims, legal, compliance, network, quality, data, and operational teams.

• Tackle root causes and implement lasting solutions.

• Evaluate member risk and care discrepancies, document clear findings, and convert complex evidence into actionable recommendations for leaders, clients, and other stakeholders.

• Develop well-supported cases for clinical and legal evaluation.

• Provide testimony in civil or criminal cases when necessary and authorized by Legal.

• Perform required peer-to-peer reviews.

• Exemplify Aetna’s Employee Competencies in all interactions.

⛳️ Requirements

• A minimum of five years of experience in a healthcare delivery environment, including clinical practice.

• Board certification in psychiatry; mere board eligibility is insufficient.

• Understanding of the policies and procedures that govern healthcare claims payments.

• M.D. or D.O. degree.

• Active and unrestricted state medical license(s).

• Five years of post-graduate experience in direct patient care.

• At least two years of experience in the healthcare industry, with familiarity in CPT and HCPCS coding guidelines (preferred).

• Experience utilizing psychiatric expertise for medical record reviews and claim-payment decisions in accordance with company, state, federal, and industry standards (preferred).

• Experience providing psychiatric insight in the creation of business analytics (preferred).

• Knowledge of advanced analytics, artificial intelligence, healthcare technology, population health data, and physician practice-pattern analysis (preferred).

• Experience collaborating with clinical, investigative, legal, compliance, data science, and operational teams to assess intricate utilization or claims patterns and achieve results (preferred).

🏝️ Benefits

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

• Equity award program.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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