[Remote] Medical Director Aetna Duals Center of Excellence at CVS Health

Connecticut, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Minimum 3-5 years of clinical practice experience
Two (+) years of experience in managed care (Medicare and/or Medicaid)
MD or DO; Board certification in an ABMS or AOA recognized specialty is required
Active and current state medical license without encumbrances is required
Preferred: Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System
Preferred: Licensed in or willing to obtain license in at least one state where we have an Integrated plan
Preferred: Experience with managed care (Medicare and Medicaid) utilization review preferred

Responsibilities

Perform concurrent and prior authorization reviews with peer to peer coverage of denials
Perform appeals in their “base plan” and in the round robin based on “same or similar specialty” needs
Perform pharmacy reviews
Participate in and be able to lead daily rounds
Ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request
Occasional weekend/holiday call to cover urgent cases from your laptop

Skills

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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