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Medical Director (Medical Policy Ops-DRG)
<p>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 <span style="overflow-wrap: break-word; display: inline; text-decoration: inherit; hyphens: auto;">ourselves accountable</span> 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.</p><p style="text-align:inherit"></p><p style="text-align:inherit"></p><p style="text-align:inherit"></p><p><b>Position Summary</b></p><p></p><p>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?<br><br>This is a remote Work at Home position and can be located anywhere in the United States.<br><br>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.</p><p></p><p>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.</p><p><br>Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.<br><br>This Medical Director may also provide subject matter expertise in clinical and payment policy to support clinical and business direction in these areas.</p><p></p><p>In addition, be a subject matter expert in DRG reviews and ICD-10 code selection.</p><p></p><p><b>Additional responsibilities may include:</b><br><br>◾Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services.<br>◾Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests.</p><p>◾Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.<br>◾ Be a subject matter expert, internal consultant and payment policy contributor.<br>◾Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company.<br>◾Work Collaboratively with the functional areas.</p><p><br><b>Required Qualifications</b></p><p>*Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.<br>*Active and current state medical license without encumbrances.<br>*M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience</p><p></p><p><b>Preferred Qualifications</b></p><p>* Health plan/payor experience.<br>* Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.</p><p>* Experience with DRG reviews.<br>* Strong communication skills both written and verbal.</p><p><br><b>Education</b><br>* M.D. or D.O.</p><p style="text-align:inherit"></p><p style="text-align:inherit"></p><p style="text-align:left"><b>Pay Range</b></p><p style="text-align:left">The typical pay range for this role is:</p><p style="text-align:inherit"></p>$174,070.00 - $374,920.00<p style="text-align:left !important"><br>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. <br> </p><p style="text-align:left !important">Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>Great benefits for great people</b></p><p></p><p>We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.<br><br></p>This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><span style="color:#4a4a4a"><br>Additional details about available benefits are provided during the application process and on </span><a href="https://learn.bswift.com/cvshealth-mainland" target="_blank" rel="noopener noreferrer"><span style="color:#0000ff"><u>Benefits Moments</u></span></a><span style="color:#4a4a4a">.<br><br></span></p>We anticipate the application window for this opening will close on: 06/12/2026<p style="text-align:inherit"></p><p style="text-align:inherit"></p><p style="text-align:left">Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p>
