Medical Director – Medicare Appeals

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

📋 Description

• Oversee the daily operations related to Part C appeals, encompassing both provider and member/nonparticipating provider appeals.

• Offer direct assistance to appeal nurses.

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

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

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

• Collaborate closely with Medicare Quality and Compliance teams.

• Cultivate subject matter expertise regarding Medicare policies for the organization.

• Deliver ongoing education regarding Medicare policies and appeals to appeal nurses and territory Utilization Management personnel.

• 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.

• A valid Medical License (MD) or (DO).

• An active state medical license free of any encumbrances.

• Board Certification in an ABMS or AOA Recognized Specialty.

• Experience in Medical Management, particularly in Medicare Complaints, Grievances & Appeals, is preferred.

• Previous experience with Health Plans is highly preferred.

• MD or DO required.

🏝️ Benefits

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

• Target award in the company’s 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.