Medical Director – Medicaid Appeals

CVS Health

Medical Director reviewing Medicaid appeals for Aetna, CVS Health’s national insurer. Providing clinical expertise on medical necessity, grievances, fair hearings, and escalated complaints.

Posted 8/12/2026full-timeRemote • Connecticut, Idaho, Minnesota, Texas • 🇺🇸 United StatesLead💰 $174,070 - $374,920 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates clinical expertise in medical necessity appeals and provides consultation to Medicaid grievance teams. Holds an active medical license and board certification in an ABMS-recognized specialty, with experience in managed care and Medicaid policy.

Highest-signal resume keywords

Active State Medical LicenseBoard Certification in ABMS-Recognized SpecialtyPost-Graduate Direct Patient Care ExperienceMedicaid Policy ExperienceManaged Care Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical PracticeMedical Necessity AppealsUtilization ManagementDynamo Appeals and Grievances (DAG)Family MedicineEmergency MedicineInternal Medicine-Pediatrics

Soft Skills

Timely ResponseConsultationLeadership

Certifications & Qualifications

M.D.D.O.

Industry Keywords

Health Care Delivery SystemMedicaid GrievanceAppeals Committee MeetingsSoutheast Region

About the role

Key responsibilities & impact

Support Medical Management staff with timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints
Focus on member and provider appeals related to medical necessity
Provide clinical expertise and consultation to the Medicaid grievance and appeals team
Chair or co-chair Medicaid appeals committee meetings
Primarily support the Southeast Region, including Florida, Kentucky, Louisiana, and West Virginia

Requirements

What you’ll need

Five (5) or more years of experience in a health care delivery system, such as clinical practice or the health care industry
Active state medical license without encumbrances
Ability to obtain Florida, Kentucky, Louisiana, and West Virginia licensure
Board certified in an ABMS-recognized specialty
M.D. or D.O.
Board certification in an ABMS- or AOA-recognized specialty
Post-graduate direct patient care experience
Preferred: Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics specialty
Preferred: Previous experience in Medicaid policy and Dynamo Appeals and Grievances (DAG)
Preferred: Prior managed care experience in utilization management
Preferred: Prior experience in appeals

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program
Award target in the company’s equity award program
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being