Medical Director (Behavioral Health)

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) full-time position and can be based anywhere in the United States.The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for 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. The expectation is that the BH Medical Director will have a high level of knowledge when providing testimony during civil and criminal proceedings. The BH Medical Director must be able to travel, as needed, and provide detailed testimony based upon the BH Medical Director's documentation- Manages the use of outside resources and vendors, in a cost-effective manner, to perform activities necessary for investigations.- Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review- Exhibits behaviors outlined in Employee Competencies.Pay RangeThe typical pay range for this role is:Minimum: 141,500Maximum: 302,500Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.Required Qualifications- Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice); 2 years' experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles- 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.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- 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.Education- 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.Business 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