Medical Director, Medical Affairs

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

📋 Description

• Deliver clinical assistance and advisory services across the PBM.

• Offer consultative clinical support to Account Management for designated key clients.

• Evaluate medication utilization requests and medical necessity appeals for commercial clients, Medicare/Medicaid programs, and individual client coverage evaluations.

• Engage in peer-to-peer discussions when necessary.

• Provide support for evening and weekend coverage across commercial, Medicare, and Medicaid sectors as required.

• Contribute to inter-rater review activities and quality oversight processes for internal Director utilization management decisions.

• Oversee segments of CVS Health’s clinical programs and provide support for commercial client programs.

• Participate in reviews of utilization management criteria and revisions of clinical policies.

• Conduct special clinical investigations and research as requested by the Senior Medical Director.

• Analyze published literature on pharmaceutical inquiries and collaborate with pharmacists within Medical Affairs and other departments.

• Assess clinical cases and coverage requests related to specialty medications, oncology treatments, biologics, and newly launched drugs.

• Integrate clinical information, assess medical evidence, and make objective, evidence-based coverage decisions.

⛳️ Requirements

• ABMS or AOA Board Certified in Internal Medicine or Family Medicine.

• CURRENT FAMILY MEDICINE OR INTERNAL MEDICINE BOARD CERTIFICATION IS MANDATORY.

• At least 5 years of clinical experience in direct patient care.

• A minimum of 2 years of proven experience in clinical outcomes.

• Strong grasp of medical statistics, regulatory bodies, and analytical programs.

• An unrestricted license to practice medicine in the state where the candidate is located.

• Must have graduated from an accredited Medical School and Residency Program.

• Hold an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia.

• Required annual Continuing Medical Education (CME) must be up to date, and the candidate must remain current in medical and management areas throughout employment.

• Proficient in MS Office Suite.

• Additional subspecialty board certification is highly preferred.

• A combination of five years of management and/or clinical experience in a managed care environment and health administration is preferred.

• A Master's Degree in Public Health Administration or an MBA is preferred.

• UM/QA certification is desired.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Award target as part of the company’s equity award scheme.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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