Senior Medical Director – Precertification

CVS Health

Senior Medical Director overseeing clinical operations for Medicare and other activities at CVS Health. Leading the Precertification Team and driving process improvements for quality care.

Posted 5/3/2026full-timeRemote • Connecticut, Louisiana, Mississippi, North Carolina, Pennsylvania • 🇺🇸 United StatesSenior💰 $184,112 - $396,550 per yearWebsite

About the role

Key responsibilities & impact

Provides strategic direction, professional oversight, and leadership throughout the precert process and other clinical operations.
Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.
Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.
Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.
Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.
Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.
Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.
Leads teams through Medicare audits and on-going audit readiness.
Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.
Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.
Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.
Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.
Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.

Requirements

What you’ll need

MD or DO with active, unrestricted license and board certification in an ABMS or AOA recognized specialty
Minimum 5 years of direct patient care in a clinical setting
Minimum 5 years in utilization management, precertification, or related roles
Deep expertise in Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references
Proven ability to interpret and apply Medicare guidelines to complex case review and decision-making
Advanced knowledge of medical coding standards, compliance requirements, and oversight of coding practices
Demonstrated leadership in managing teams, driving process improvement, and ensuring regulatory compliance
Successful track record guiding teams through Medicare audits and maintaining audit readiness
Strong interpersonal, communication, and cross-functional stakeholder management skills
Commitment to developing talent and fostering an inclusive, high-performing team culture

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical operationsutilization managementprecertificationMedicare regulationsmedical coding standardsregulatory complianceclinical protocolstreatment pathwaysaudit readinessperformance metrics

Soft Skills

leadershipinterpersonal skillscommunication skillsstakeholder managementmentorshipteam developmentprocess improvementstrategic directioncollaborationproblem-solving

Certifications

MDDOboard certification