Medical Director - Keystone Market

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.

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) role preferably resides in PA/DE/WV  and have an active and current US medical license without encumbrances. 

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 / quality assurance and be responsible for predetermination reviews.

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 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.

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

*Active and current state medical license

*Active and current state medical license in either PA/WV/DE state without encumbrances

* Previous UM experience with a Health Plan/Payor.

The typical pay range for this role is: