Medical Director (Medicare/Medicaid)

Job DescriptionAetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work from home) role and can be based anywhere in the US.The Aetna Duals Center of Excellence (COE) operates Duals managed care plans in five states: Ohio, Illinois, Michigan, Virginia, and New Jersey offering a variety of physical and behavioral health programs and services to its membership. Aetna is looking for a Medical Director(Medicare/Medicaid) to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request. The medical director is a work-at-home position supporting the COE.Fundamental Components: Utilization management - The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials. Appeals - The medical director will perform appeals in their "base plan" and in the round robin based on "same or similar specialty" needs. Pharmacy coverage - The medical director will perform pharmacy reviews. The medical director will participate in and be able to lead daily rounds.Required Qualifications Minimum 3 or more years of clinical practice experience. 2 or more years of experience in managed care (Medicare and/or Medicaid) Experience with managed care (Medicare and Medicaid) utilization review preferred Active Board certification in a recognized specialty is required. Active and current state medical license without encumbrances is required. Multiple state licensure a plus.COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications License in : OH, MI, IL, VA, NJ or NY a plusEducationActive and current state medical license without encumbrancesM.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experienceBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15