Medical Director - Florida

About the role

At CVS Health®, we're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. 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.

Responsibilities

• Provide oversight for medical policy implementation
• 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
• Support the Medical Management staff ensuring timely and consistent responses to members and providers
• Focus primarily on overseeing utilization review/quality assurance and be responsible for predetermination reviews and reviews of claim determinations, including Prior Authorization, Pre-Certification, Concurrent Reviews, Peer to Peer Calls, First Level Appeals, Special Projects, and Committee participation when needed
• Provide clinical, coding, and reimbursement expertise as well as directing case management when necessary
• Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities
• 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

Required Qualifications

• 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 (FL preferred)
• M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience

Preferred Qualifications

• Previous UM experience with a Health Plan/Payor

Education

• MD or DO

Pay

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.

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources based on eligibility