Medical Director - Medicare (Medical Policy & Operations), CVS Health

CVS Health

Location:
United States, Work at Home

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

174070.00 - 374920.00 USD / Year

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Job Description:

Medical Director role 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 for Aetna, a CVS Health company.

Job Responsibility:

Provide clinical expertise and business direction in support of medical management programs
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
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
Work Collaboratively with the functional areas

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 have:

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

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
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:
November 22, 2025

Expiration:
December 15, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Medical Director - Medicare (Medical Policy & Operations)