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Job Information

CVS Health Medical Policy and Operations- Medical Director in Detroit, Michigan

Job Description

Aetna, a CVS Health company has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 5 company?

In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for 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 clinical and payment policy. This Medical Director provides subject matter expertise to provide clinical support and business direction in these areas. Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.

This is a remote Work at Home position and can be located anywhere in the United States.

Fundamental Components

Responsibilities of the Medical Director include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the commercial and Medicare environment. This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas.

In this role you will:

  • 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 insure 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.

  • Work on the Aetna Clinical Policy Bulletin (Clinical Policy) as a policy contributor.

  • Be a subject matter expert and 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.

Background Experience

  • 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

  • M.D. or D.O.

  • Foundational baseline skills include Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.

  • Strong communication skills both written and verbal.



Percent of Travel Required

0 - 10%

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.