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CVS Health Logo CVS Health · IT - Administration

Medical Director, Behavioral Health - SIU

United States, Work at Home Employment contract 174070.00 - 374920.00 USD / Year · Job Posted June 16, 2026
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Job Description

We're building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Job Responsibility

  • Performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse
  • Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases
  • Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse
  • Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions
  • Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna's approach to fighting fraud
  • Maintains open communication with constituents within the company
  • Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse
  • Researches and prepares cases for clinical and legal review
  • Documents all appropriate information related to medical record review determinations
  • Represents Aetna as a witness in court actions, as required, and as approved by Legal
  • Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review
  • Exhibits behaviors outlined in Employee Competencies

Requirements

  • Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice)
  • Board Certified Psychiatrist not 'Board Eligible' - Active and Unencumbered license to practice medicine
  • Knowledge of pertinent policies and procedures related to claims payment of healthcare related services
  • Active and current state medical license(s) without encumbrances - M.D. or D.O., Board Certification in psychiatry, including 5 years of post-graduate direct patient care experience

Nice to have

  • 2 years’ experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles
  • Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines
  • Psychiatric experience in providing clinical guidance and input in the business analytic building process
  • Child and Adolescent Psychiatrist

What we offer

  • Medical, dental, and vision coverage
  • Paid time off
  • Retirement savings options
  • Wellness programs
  • CVS Health bonus, commission or short-term incentive program
  • Equity award program award target
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