Medical Director - Commercial Appeals

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 SummaryAetna, 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.This is a remote based (work from home) role and m ust have a California medical license and be willing to obtain an Arizona medical license.Preferred candidates will have Internal Medicine or Internal Medicine/Pediatrics (Med/Peds) Board Certification.In the Medical Director role, you will provide oversight for medical policy implementation.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 review appeal cases for denied medical services.This includes First Level Appeals / Second Level Appeals / Expedited Appeals / Appeal Hearings / 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.The Medical Director will act as a business and clinical liaison to network providers and facilities if needed, to support the effective execution of medical services programs by the clinical teams.Required QualificationsTwo (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.Prior UM (Utilization Management) experienceActive and current state medical license in CA without encumbrances and willing to obtain an AZ medical license.M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.Preferred QualificationsInternal Medicine backgroundHave experience in Medicare and MedicaidEducationM.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.Pay RangeThe typical pay range for this role is:$174,070.00 - $374,920.00This 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 | CVS Health (https://jobs.cvshealth.com/us/en/benefits)We anticipate the application window for this opening will close on: 12/27/2024Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.