Medical Director - Midland States

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. 

• 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 and quality assurance while being responsible for predetermination reviews and review of claim determinations.

• 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, coding, and reimbursement 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.

• Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

• Active and current medical license without encumbrances

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

• Previous UM experience with a Health Plan / Payor/ Physician Advisor in a Healthcare system. 

• Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Med / Peds / General Surgery Preferred.

The typical pay range for this role is: