Medical Director (Medical Policy Ops-DRG)

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, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company?

This is a remote Work at Home position and can be located anywhere in the United States.

In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.

The Primary Responsibilities of this  Medical Director role include transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Commercial and Medicare environments.

*Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
*Active and current state medical license without encumbrances.
*M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience

* Health plan/payor experience.
* Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.

* Experience with DRG reviews.
* Strong communication skills both written and verbal.

The typical pay range for this role is: