Medical Director-Medicaid (ABH VA)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary:

Join Aetna, a CVS Health company, and make a meaningful impact on the health and well-being of Medicaid members across the country.

Aetna operates Medicaid managed care plans in Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia, and West Virginia.

We are seeking a Medical Director to join our centralized Medical Management team. This work-from-home position will primarily support Aetna Better Health of Virginia, while also providing support across the Northeast Region (Maryland, New Jersey, New York, and Pennsylvania) and other health plans as needed.

In this role, you will partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers. Key responsibilities include:

• Utilization Management and medical necessity reviews

• Prior authorization and precertification determinations

• Concurrent review for inpatient and outpatient services

• Acute and post-acute care reviews

• Peer-to-peer consultations with treating providers

• Pharmacy reviews and first-level appeal determinations

• Collaboration with multidisciplinary clinical and operational teams

The Medical Director also participates in a rotating on-call schedule that includes weekend and holiday coverage.

If you are a physician leader who is passionate about improving quality, access, and outcomes for Medicaid populations, we would love to connect with you.

• M.D. or D.O. degree with current, active Board Certification in an ABMS- or AOA-recognized specialty.

• 5+ years of post-residency clinical practice and direct patient care experience.

• • Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.

  • Prior Utilization Management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity.

  • Medicaid and managed care experience.

  • Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation.

  • Experience using electronic health records and other clinical documentation systems.

• M.D. or D.O., Board Certification in ABMS or AOA recognized specialty including post-graduate direct patient care experience.

The typical pay range for this role is: