Medical Director – Medicare Appeals

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

📋 Description

• Oversee daily operations related to Part C appeals, which include appeals from providers and members/nonparticipating providers.

• Offer direct assistance to appeal nurses.

• Manage and take part in the Second Look Review (SLR) process.

• Provide after-hours and weekend support on a rotational schedule to ensure continuous 24/7 appeal operations.

• Track and monitor IRE activities while supporting the Utilization Management Strategy.

• Work in collaboration with Medicare Quality and Compliance teams.

• Cultivate subject matter expertise in Medicare policy across the organization.

• Deliver ongoing training regarding Medicare policy and appeals to appeal nurses and Utilization Management staff in the territory.

• Engage in initiatives aimed at enhancing the efficiency of the appeals team and ensuring clinical consistency.

⛳️ Requirements

• A minimum of two (2) years of experience within a Health Care Delivery System, such as Clinical Practice or the Health Care Industry.

• Hold a Medical License (MD) or (DO).

• Possess an active state medical license free of encumbrances.

• Board Certification in an ABMS or AOA recognized specialty.

• MD or DO degree required.

• Preferred experience in Medical Management, particularly with Medicare Complaints, Grievance, and Appeals.

• Health Plan experience is highly desirable.

🏝️ Benefits

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

• Opportunity for an award target within the company’s equity award program.

• Comprehensive medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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