Medical Director - Midland States

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Summary : Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.  This is a remote based (work from home) position. Ideal Candidates will reside in Midlands States (IL, MO,  MN, WI) and have a medical license without encumbrances in one of these states. In the Medical Director role you will provide oversight for medical policy implementation. You will participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care. You will support the Medical Management staff ensuring timely and consistent responses to members and providers. As a Medical Director you will focus primarily on overseeing utilization review and quality assurance while being responsible for predetermination reviews and review of claim determinations. This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.  The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary. In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities. The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Active and current medical license without encumbrances M.D. or D.O., Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

Previous UM experience with a Health Plan / Payor/ Physician Advisor in a Healthcare system.  Board Certification in Internal Medicine, Family Medicine, Emergency Medicine or Med / Peds / General Surgery Preferred.

Medical Doctor or Doctor of Osteopathic Medicine Pay Range The typical pay range for this role is: $174,070.00 - $374,920.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.  This position also includes an award target in the company’s equity award program.    Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support