Medical Director at CVS Health in United States

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Job Description
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 5 company?

The Medical Director is a remote based (work from home) role. Ideally the candidate will reside in: PA, DC, WV or DE, but can consider other locations.

The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of utilization management reviews and medical management programs to promote the delivery of high quality, constituent responsive medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsor, and regulatory agencies. The Medical Director will partner with caremanagement to increase effectiveness of medical management programs and promote integration of other Aetna medical programs




Fundamental Components
In this role you will:
  • Manage UM transactional work (front line reviews and appeals) which will be 80%-90% of the role.
  • Build and inspire a culture of continuous improvement for better quality of care.
  • Oversee utilization review/quality assurance directing case management
  • Provide UM services based on business demands and shifting business needs
  • Helplead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits.
  • Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (e.g. telephonic rounds) in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management.
  • Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.
  • Proactively use data analysis to identify opportunities for overall value improvement (including both financial as well as quality improvement), to positively influence the effective delivery of quality care.
  • Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.
  • Work collaboratively with other functional areas that interface with medical management including provider relations, sales, benefits, healthcare delivery, national medical services and national accounts to achieve the business goals of the company.
  • Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.
  • Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved.


Background Experience
  • 2 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 a recognized specialty including post-graduate direct patient care experience.


Education
MD

Percent of Travel Required
0 - 10%

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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