Medical Director - Medicaid Appeals

Join Us At CVS Health

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.

Aetna, a CVS Health Company, a Fortune 6 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 role primarily supports the Southeast Region (Florida, Kentucky, Louisiana & West Virginia).

This is a remote based (work at home) based anywhere in the US.

• You will support the Medical Management staff ensuring timely and consistent responses to member and provider appeals, state fair hearings, and escalated complaints
• As a Medical Director you will focus primarily on member and provider appeals related to medical necessity
• You will provide clinical expertise and consultation to the Medicaid grievance and appeals team
• You will chair/co-chair Medicaid appeals committee meetings.

• Five (5) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
• An Active state medical license without encumbrances as well as the ability to obtain FL, KY, LA & WV licensure
• Board Certified in ABMS Recognized Specialty

• Family Medicine, Emergency Medicine, Internal Medicine-Pediatrics specialty
• Previous experience in Medicaid Policy and the use of Dynamo Appeals and Grievances (DAG)
• Prior managed care experience in utilization management
• Prior experience in appeals

M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.

The typical pay range for this role is:

$ - $

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

This position also includes an award target in the company's equity award program.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.