Medical Director DRG (Medical Policy & Operations), 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:

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:

Support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment
Be a subject matter expert in DRG reviews and ICD-10 code selection
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

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 DRG reviews
Strong communication skills both written and verbal

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 01, 2025

Expiration:
August 25, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Medical Director DRG (Medical Policy & Operations)