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.

• Conduct transactional assessments to support the appeal process, clinical claim evaluations, and the 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 that enhance the quality and efficiency of healthcare services.

• Utilize clinical coding and reimbursement knowledge to ensure the correct alignment and application of Aetna policies and practices regarding service and payment requests.

• Leverage data analysis to pinpoint quality improvement opportunities and effectively enhance the 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.

• Partner with various functional areas.

⛳️ Requirements

• A minimum of five (5) years of experience in the Health Care Delivery System, including Clinical Practice and the Health Care Industry.

• An active and current state medical license free of encumbrances.

• M.D. or D.O. degree.

• Board Certification in a specialty recognized by ABMS.

• Post-graduate direct patient care experience.

• Experience with health plans or payors is preferred.

• Foundational skills in Medicine, Health Policy, Coding (HCPCS/CPT), Clinical Policy, Reimbursement, and Health Care Systems are preferred.

• Strong written and verbal communication skills are 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 supporting physical, emotional, and financial well-being.