Medical Director – Medical Policy & Operations

CVS Health

Medical Director role at CVS Health focusing on clinical and payment policy in healthcare delivery. Responsibilities include clinical reviews and collaborative work with health delivery professionals.

Posted 5/9/2026full-timeRemote • Connecticut • 🇺🇸 United StatesLead💰 $174,070 - $374,920 per yearWebsite

About the role

Key responsibilities & impact

providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy
transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Medicare and commercial environments, with emphasis on Medicare clinical and payment 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
be a subject matter expert, internal consultant and payment policy contributor
work collaboratively with the functional areas

Requirements

What you’ll need

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

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 expertisecoding expertisereimbursement expertisedata analysisclinical claim reviewtransactional reviewsquality improvementpayment policy applicationhealth care services efficiencypredetermination of covered benefits

Soft Skills

collaborationconsultationcommunicationleadershipproblem-solvinginterpersonal skillssubject matter expertiseorganizational skillsinfluenceteamwork

Certifications

M.D.D.O.Board Certificationstate medical license