CVS Health

The ideal candidate will have familiarity with the Massachusetts market – hospitals, outpatient networks, and value-based care relationships.. You will participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.. The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS).

medical director

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.
Position Summary
Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.
This is a remote based (work from home) position for the New England Region. The preferred candidate will reside in Connecticut, Rhode Island, Massachusetts, Vermont, New Hampshire or Maine with Massachusetts location highly preferred. The ideal candidate will have familiarity with the Massachusetts market – hospitals, outpatient networks, and value-based care relationships.
The Medical Director will be required to have a Massachusetts state medical license without encumbrances; or the ability to obtain the license within a reasonable timeframe.
The Medical Director will be responsible for Account Management and Relationship Management with one or more Hospital / Health systems in the Region. This will require that the Medical Director interact on a regular basis via Microsoft Teams Meetings and other “Outward Facing Capable” Technologies.
A demonstrated track record and history of teamwork and collaboration is required; and necessary in order to be a successful member of the New England Region Medical Director Team.
In the Medical Director role you will provide oversight for medical policy implementation.
You will participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.
You will support the Medical Management staff ensuring timely and consistent responses to members and providers.
As a Medical Director you will focus primarily on overseeing utilization review and quality assurance while being responsible for predetermination reviews and review of claim determinations.
This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.
The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary.
In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Required Qualifications:
Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Active and current medical license without encumbrances
M.D. or D.O., Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Preferred Qualifications:
Residence in one of the states in the New England Region
Previous UM experience with a Health Plan / Payor.
Previous UM experience as a Physician Advisor in a Health / Hospital system.
Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine Preferred.

Education:
Medical Doctor or Doctor of Osteopathic Medicine
Pay Range
The typical pay range for this role is:
$169,000.00 - $364,000.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits
We anticipate the application window for this opening will close on: 04/30/2024
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
CVS Health is committed to recruiting, hiring, developing, advancing, and retaining individuals with disabilities. As such, we strive to provide equal access to the benefits and privileges of employment, including the provision of a reasonable accommodation to perform essential job functions. CVS Health can provide a request for a reasonable accommodation, including a qualified interpreter, written information in other formats, translation or other services through ColleagueRelations@CVSHealth.com If you have a speech or hearing disability, please call 7-1-1 to utilize Telecommunications Relay Services (TRS). We will make every effort to respond to your request within 48 business hours and do everything we can to work towards a solution.

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