Medical Director - Medicare Appeals

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Position Summary

Aetna, a CVS Health Company, a Fortune 6 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 at home) based anywhere in the US.

Responsibilities of this Medical Director role are related to Medicare Appeals.

• Direct daily work on part C appeals (both provider and member / nonparticipating providers) and Part D appeals.
• Provide direct support to appeal nurses and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process
• Provide direct support to the Quality Review nurses

Provide after hours and weekend coverage on a rotational basis to support 24 / 7 appeals work

• IRE monitoring and tracking and Utilization Management Strategy support
• Collaborative work with Medicare Quality and Compliance on an ongoing basis
• Develop subject matter expertise on Medicare policy for the enterprise
• Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff
• Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency

Required Qualifications

• Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
• Medical License (MD) or (DO)
• An Active state medical license without encumbrances
• Board Certified in ABMS Recognized Specialty

Preferred Qualifications

• Medical Management - Medicare Complaints, Grievance & Appeals experience.
• Health Plan Experience Highly Preferred

Education

Please replace this section with the Education Requirements

Pay Range

The typical pay range for this role is :

$174,070.00 - $374,900.00

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.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.