Medical Director – Medical Policy Ops, DRG

CVS Health

Medical Director providing clinical expertise in medical policy and operations for CVS Health. Responsible for clinical and payment policy, reviews, and subject matter expertise.

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
predetermination of covered benefits in the Commercial and Medicare environments
participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve 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

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical codingdata analysisclinical claim reviewpredetermination of benefitsreimbursement expertise

Soft Skills

clinical expertisequality improvementefficiency promotioncommunication

Certifications

M.D.D.O.Board Certification