Clinical Director – Dental
Centene Corporation
Medical Director – Special Investigations Unit
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Remote • California, Minnesota, Texas, Vermont • 🇺🇸 United States
Visit company websiteSalary
💰 $174,070 - $374,920 per year
Job Level
Lead
About the role
- Perform reviews of medical records in support of healthcare fraud investigations
- Serve as a clinical liaison supporting SIU Investigators, Managers, and Directors across all lines of business
- Make pre- and post-payment claim payment determinations based on Aetna Clinical Policy and/or state and federal regulations
- Develop and deliver presentations to internal and external customers regarding healthcare fraud matters and Aetna’s approach to fighting fraud
- Provide clinical expertise and business direction in the creation of analytical solutions designed to identify potentially fraudulent scenarios
- Use available resources and technology to develop evidence supporting allegations of fraud, waste, or abuse
- Document all appropriate information related to medical review determinations
- Proactively build relationships with other internal MDs to obtain clinical guidance for accurate decision making
- Represent Aetna as a witness in legal matters and provide expert medical testimony as required and approved by Legal
- Conduct peer-to-peer reviews of SIU-related claims and perform root cause analysis to identify control gaps
- Mentor and educate SIU team members on clinical aspects of fraud schemes
Requirements
- MD or DO with active license, preferably in emergency medicine or primary care
- 5+ years of clinical practice experience
- Strong analytical and problem-solving skills
- Excellent communication and leadership abilities
- 3+ years supporting healthcare fraud investigations or related field (Preferred)
- Board Certification in Emergency Medicine (Preferred)
- Active and current state medical license without encumbrances
- M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience
- Ability to represent Aetna/CVS Health as a witness in legal matters and provide testimony during civil or criminal proceedings
- Experience making pre- and post-payment claim payment determinations based on clinical policy and/or state and federal regulations
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
- Eligible for CVS Health bonus, commission or short-term incentive program
- Award target in the company’s equity award program
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical practiceanalytical solutionsmedical record reviewclaim payment determinationsroot cause analysisfraud investigationclinical expertiseevidence developmentpeer-to-peer reviewspresentation development
Soft skills
analytical skillsproblem-solving skillscommunication abilitiesleadership abilitiesrelationship buildingmentoringeducatingdecision making
Certifications
MDDOBoard Certification in Emergency Medicineactive state medical license
