Medical Director - Medicare (Medical Policy & Operations)
About the position At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryAetna, a CVS Health company, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company?This is a remote Work at Home position and can be located anywhere in the United States.In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.This Medical Director provides subject matter expertise to provide clinical support and business direction in these areas.Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.The Primary Responsibilities of this Medical Director role include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment with a focus Medicare policy.,This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas. In this role you will:Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services.Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests.Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services. Be a subject matter expert, internal consultant and payment policy contributor subject matter expertise and internal consultant.Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company.Work Collaboratively with the functional areas. Responsibilities • Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services. • Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. • Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services. • Be a subject matter expert, internal consultant and payment policy contributor subject matter expertise and internal consultant. • Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company. • Work Collaboratively with the functional areas. • Support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment with a focus Medicare policy. Requirements • 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. • M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience Nice-to-haves • Health plan/payor experience. • Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems. • Experience with Medicare policies and guidelines (National Coverage Determination (NCD), Local Coverage Determination (LCD), Local Coverage Article (LCA) and Medicare manuals) • Strong communication skills both written and verbal. Benefits • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. Apply tot his job