Medical Director - Medicare Appeals

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.

Position Summary

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

Responsibilities of this Medical Director role are related to Medicare Appeals

* Direct daily work on part C appeals (both provider and member/nonparticipating providers) * Provide direct support to appeal nurses; supervision and participation in the Second Look Review (SLR) process * Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work * IRE monitoring and tracking and Utilization Management Strategy support * Collaborative work with Medicare Quality and Compliance on an ongoing basis * Develop subject matter expertise on Medicare policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff * Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency Required Qualifications

• Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
• Medical License (MD) or (DO)
• An Active state medical license without encumbrances
• Board