Medical Director – Medical Policy, Operations
CVS Health
Medical Director – Medicare, Medical Policy & Operations
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Remote • California, Idaho, Vermont • 🇺🇸 United States
Visit company websiteSalary
💰 $174,070 - $374,920 per year
Job Level
Lead
About the role
- Provide clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy
- Support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment with a focus Medicare policy
- 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
- Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests
- Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services
- Work collaboratively with functional areas
Requirements
- Five (5) 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 an ABMS recognized specialty including post-graduate direct patient care experience
- Health plan/payor experience (preferred)
- Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems (preferred)
- Experience with Medicare policies and guidelines (National Coverage Determination (NCD), Local Coverage Determination (LCD), Local Coverage Article (LCA) and Medicare manuals) (preferred)
- Strong communication skills both written and verbal
Benefits
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical codingreimbursementdata analysishealth policyHCPCSCPTMedicare policiesNational Coverage DeterminationLocal Coverage DeterminationLocal Coverage Article
Soft skills
communicationcollaborationclinical expertisebusiness directionquality improvementefficiency improvement
Certifications
M.D.D.O.Board Certification
