Medical Director - DSNP/MMP, 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

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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:

Responsible for clinical oversight of DSNP/MMP complex populations
Develop and lead clinical strategy and objectives for the DSNP/FIDE populations
Leverage extensive knowledge of health care delivery system, utilization management, reimbursement methods and treatment protocols for DSNP/MMP and other complex health populations
Actively participate in meetings and communication with the State Department of Medicaid
Outward facing position to interact and collaborate with medical / physical professional associates, the local provider community, state regulatory agencies and advocacy groups
Develop and guide the implementation of Medical Management programs
Work collaboratively with the Behavioral Health, Pharmacy, Member Outreach, Care Management, National Quality Management, Utilization Management, Compliance, and other departments
In collaboration with health care analytics teams, develop analytical models, interpret results, and extract insights on the clinical drivers and trends
Effectively communicate these finding to Senior Management and staff at all levels
Develop and deliver conference presentations or other presentations
Actively participate in State Fair Hearings as needed and state calls
Confer directly with providers regarding the care of patients with severe, complex, and/or treatment resistant illnesses
Work with medical director teams focusing on inpatient care management, clinical coverage review, member appeals clinical review, medical claim review, and provider appeals clinical review
Actively participate in scheduled team meetings and leadership meetings
Facilitate Interdisciplinary Care Team rounds for DSNP/MMP members
Develop effective working relationships with internal clinical team, facilitate educational and coaching opportunities for the internal clinical team
Partner with appropriate entities in the investigation of potential quality of care concerns and/or grievances
Actively support compliance functions to maintain standardized systems, policies, programs, procedures, and workflows
Support the activities of other plan leadership as required or assigned
Be an active voice and participate in all internal and external committee meetings
Actively participate in quality improvement activities internal and external to the organization with multiple stakeholders
Help achieve or exceed all applicable HEDIS, Stars and local state performance targets and goals otherwise specified for the plan
Support all Clinical Quality initiatives and peer review processes including Quality of Care and Quality of Service (grievance) issues
Actively participate in or lead quality and/or member/provider service-focused committees
Provide clinical leadership in preparation for program audits and/or certification processes

Requirements:

MD or DO Degree and Currently Board Certified in Internal Medicine, Family Medicine, or Geriatric Medicine
Licensed in at least one state with the ability to get licensure in Ohio, New York, New Jersey, Virginia, Michigan, Florida and others as needed
Florida Location and Florida License is REQUIRED
Active Unrestricted Board Certification in ABMS or AOA specialty
Five 5+ years of clinical practice experience post residency, including experience with complex health populations and services (must have at least three years of training in a medical specialty)
Three 3+ years of experience in the managed care industry
Experience in leading interdisciplinary teams
Solid understanding of and concurrence with evidence-based medicine (EBM) and managed care principles
Ability to travel on as needed basis
Proven ability to develop relationships with network and community physicians and other providers

What we offer:

Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
August 12, 2025

Expiration:
August 29, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Medical Director - DSNP/MMP

CVS Health

Location:United States, Work At Home

Category:Health and Beauty

Contract Type:Not provided