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Medical Director - Medical Policy & Operations (DRG Team) - Remote Eligible

Lead initiatives to enhance clinical and payment policy for improved healthcare delivery.
Remote
Senior
$174,070 - 374,920 USD / year
3 weeks ago
CVS Health

CVS Health

CVS Health is a leading pharmacy and healthcare company offering prescriptions, products, and wellness services.

✨ About The Role

- The Medical Director will provide clinical expertise and business direction to support medical management programs focused on high-quality, constituent-focused medical care. - Responsibilities include supporting the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits in both Commercial and Medicare environments. - The role requires participation in work groups as a clinical subject matter expert to identify and promote opportunities for improving healthcare service quality and efficiency. - The Medical Director will apply clinical coding and reimbursement expertise to ensure alignment with Aetna policies and practices. - Proactive data analysis will be utilized to identify quality improvement opportunities and influence the effective delivery of care services.

âš¡ Requirements

- The ideal candidate will have at least five years of experience in the healthcare delivery system, demonstrating a strong understanding of clinical practice and the healthcare industry. - A current and active state medical license is essential, ensuring the candidate is qualified to provide medical expertise. - Candidates should possess an M.D. or D.O. degree, with board certification in an ABMS recognized specialty and relevant post-graduate direct patient care experience. - Strong communication skills, both written and verbal, are crucial for effectively collaborating with diverse health delivery professionals. - Experience in health plan or payor environments, particularly with DRG reviews, will be highly beneficial for this role.
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Medical Director - Medical Policy & Operations (DRG Team) - Remote Eligible
Remote
$174,070 - 374,920 USD / year
Healthcare Administration
About CVS Health
CVS Health is a leading pharmacy and healthcare company offering prescriptions, products, and wellness services.