Medical Director Aetna Duals Center of Excellence

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:

The Aetna Duals Center of Excellence (COE) operates Duals Integrated Plans: Ohio, Illinois, Michigan, Virginia, Pennsylvania, and New Jersey offering a variety of physical and behavioral health programs and services to its membership.

Aetna is looking for a medical director to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request. The medical director is a work-at-home position located anywhere in the US. 

The Medical Director will be required to work Eastern or Central Standard time 8-5. Occasional weekend/holiday call to cover urgent cases can be done from your laptop.

Fundamental Components:

• Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials.
• Appeals – The medical director will perform appeals in their “base plan” and in the round robin based on “same or similar specialty” needs.
• Pharmacy coverage – The medical director will perform pharmacy reviews.
• The medical director will participate in and be able to lead daily rounds.

Required Qualifications:

Minimum 3-5 years of clinical practice experience.

Two (2) + years of experience in managed care (Medicare and/or Medicaid)

Experience with managed care (Medicare and Medicaid) utilization review preferred

MD or DO; Board certification in an ABMS or AOA recognized specialty is required.

Active and current state medical license without encumbrances is required. Multiple state licensure a plus.

Preferred Qualifications:

Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System.

Licensed in or willing to obtain license in at least one state where we have an Integrated plan.

Education

MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine)

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 nearmejobs.eu CVS Health

We anticipate the application window for this opening will close on: 01/31/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Read Full Description