Behavioral Health Medical Director, CVS Health

CVS Health

Location:
United States, Work At Home

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

174070.00 - 374920.00 USD / Year

Save Job

Job offer has expired

Job Description:

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.

Job Responsibility:

Directs the utilization review process and oversee the quality of utilization determinations
Responsible for overall medical policies to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of Behavioral Health Medical Director Staff
Responsible for recommending changes and enhancements to current member management, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols
Ensuring consistency in the application of utilization management standards, including those implemented by subcontracted entities for BH services
Review and resolution of quality-of-care concerns
Participation in clinical staff recruitment and ongoing performance improvement
Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise
Support submission and completion of Potential Quality of Care Determinations (PQOC) and complete reviews as needed
Participate in BH transition of care (TOC) rounds and care management activities as needed
Will serve as a collaborator with Duals Center of Excellence in designated markets to ensure compliance with UM and quality programs and support initiatives, programs, and solutions
Support duties as required regarding utilization management of the service benefit and pharmacy benefit within the state health plan and additional duties as assigned
Actively participate in continuous improvement activities, other activities that support quality of care and total cost of care oversight

Requirements:

Three (3) or more years of experience in post-residency training clinical practice
Three (3) or more years administrative experience in the health care industry or managed care
Independently motivated and capable of researching and adjudicating Medicare and Medicaid benefit and coverage decisions
Strong communication skills both written and verbal
Board Certification in ABMS recognized specialty of Adult Psychiatry
Current and Active State Medical License without encumbrances
Able to get additional licenses in key states, where required
Ability to attend in-person meetings and manage after-hours/ on-call consultations when needed

Nice to have:

Previous UM experience with a Health Plan or Health / Hospital System
Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts
Previous Medicare and Medicaid experience
Experience in managing behavioral health services

What we offer:

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

Additional Information:

Job Posted:
April 24, 2025

Expiration:
April 30, 2025

Employment Type:

Fulltime

Work Type:

Remote work

View All Jobs In This Company

Job Link Share:

Behavioral Health Medical Director