Medical Director – Medical Policy, Operations

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

📋 Description

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

• Execute transactional reviews that support the appeals process.

• Carry out clinical claim evaluations.

• Conduct predetermination 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 identify and advocate for opportunities to enhance healthcare quality and efficiency.

• Utilize clinical coding and reimbursement knowledge to guarantee accurate implementation of Aetna policies and practices related to service and payment requests.

• Leverage data analysis to pinpoint quality improvement opportunities and positively impact the provision 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 company business objectives.

• Work in conjunction with various functional areas.

⛳️ Requirements

• A minimum of one year of experience working within a health insurance company.

• Five (5) or more years of experience in a healthcare delivery system, including clinical practice and the healthcare industry.

• An active and current state medical license without any encumbrances.

• M.D. or D.O. degree.

• Board Certification in a specialty recognized by ABMS.

• Post-graduate experience in direct patient care.

• Foundational skills in medicine, health policy, coding (HCPCS/CPT), clinical policy, reimbursement, and healthcare systems.

• Excellent written and verbal communication abilities.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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

• Equity award program.