Executive Medical Director, Commercial

CVS Health

Executive Medical Director leading clinical management activities for Aetna under CVS Health. Driving strategies to optimize member care, quality, and cost across the healthcare continuum.

Posted 6/17/2026full-timeRemote • Connecticut • 🇺🇸 United StatesLead💰 $227,630 - $490,280 per yearWebsite

About the role

Key responsibilities & impact

Lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality, cost, and outcomes.
Direct the utilization review process and oversee the quality of utilization determinations, including case reviews, peer to peer provider discussions, and appeals.
Ensure compliance with clinical goals through monitoring of care management performance.
Oversee application of medical policies to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of medical management staff.
Recommend changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
Develop, implement, and interpret medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
Lead clinical staff in the coordination of quality care.
Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Analyze policy/procedure/workflows on case management and utilization management for redesign and efficiency opportunities.
Act as lead clinical liaison to select plan sponsors including reviewing clinical trends, exploring new clinical strategies, handling escalations, and supporting sales and renewal activities as needed.
Support and train SMDs and MDs on such activities.
Identify and advance new affordability initiatives for the Commercial line of business, not limited to medical policy and utilization review activities.
Monitor KPIs and trends to understand value and opportunities and expand Aetna's medical management programs to address member needs across the continuum of care.
Provide clinical support for UM/CM/Appeals complex or escalated cases as appropriate.
Participate in an on‑call rotation, including occasional weekend coverage.

Requirements

What you’ll need

Five (5) or more years of experience in clinical practice
Five (5) or more years administrative experience in the health care industry or managed care
Demonstrated experience with utilization management, care management, and applicable state and federal regulations
Prior experience leading and developing physician leaders and/or multidisciplinary clinical teams
Demonstrated ability to use data and analytics to inform clinical and business decisions
Proven capability to drive process improvement initiatives and lead change in a complex, matrixed organization
Effective and professional communication skills to engage diverse audiences, including executives, providers, and clients
Ability to manage multiple priorities in a fast‑paced environment
Strategic thinking and planning skills aligned with business objectives
Ability to work in a virtual environment, with periodic business travel (approximately 10%)

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

utilization managementcare managementclinical practice guidelinesmedical necessity criteriadata analyticsprocess improvementmedical policy developmenttreatment protocolsKPI monitoringclinical expertise

Soft Skills

leadershipcommunicationstrategic thinkingorganizational skillsability to manage multiple prioritiescollaborationproblem-solvingadaptabilitytrainingengagement