Medical Director – Regulated Medicare Appeals

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, a Fortune 6 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 at home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Regulated Medicare Appeals: • Direct daily work on part C appeals (both provider and member/nonparticipating providers). • Provide direct support to appeal nurses and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process. • Provide direct support to the Quality Review nurses. • IRE monitoring and tracking and Utilization Management Strategy support. • Develop subject matter expertise on Medicare policy for the enterprise. • Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management staff. • Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency. Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work. Required Qualifications • Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry • Medical License (MD) or (DO) • An Active state medical license without encumbrances • Board Certified in ABMS Recognized Specialty Preferred Qualifications • Medical Management – Medicare Complaints, Grievance & Appeals experience. • Health Plan Experience Highly Preferred Education • Medical License (MD) or (DO) Pay Range The typical pay range for this role is: $174,070.00 – $374,920.00 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 Benefits | CVS Health We anticipate the application window for this opening will close on: 02/28/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply Job!