Medical Director – Medical Policy Ops, DRG
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Connecticut • United States
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Salary
💰 $174,070 - $374,920 per year
Job Level
About the role
- Responsible for providing clinical expertise and business direction in support of medical management programs.
- Promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.
- Support the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits.
- Be a subject matter expert in DRG reviews and ICD-10 code selection.
- Proactively use data analysis to identify opportunities for quality improvement.
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.
- Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.
- Experience with DRG reviews.
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.
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
- 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 & Tools
data analysisICD-10 code selectionDRG reviewsHCPCS codingCPT codingclinical claim reviewpre-certificationpredetermination of benefitsclinical policyreimbursement
Soft Skills
clinical expertisebusiness directionquality improvementconstituent focused care
Certifications
M.D.D.O.Board Certification