Medical Director-Medicaid (ABH TX)

Texas Twp, Michigan, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Managed Care, MedicaidIndustries

Requirements

Candidates must possess an active and current Texas state medical license without encumbrances and be able to obtain additional licenses. A M.D. or D.O. degree with current and active Board Certification in an ABMS or AOA recognized specialty, including post-graduate direct patient care experience in Family Medicine, Emergency Medicine, Internal Medicine, or Pediatrics is required, along with five or more years of experience in a Health Care Delivery System. Prior UM experience, experience as a Physician Advisor, experience with an Independent Review Organization, electronic medical systems/record experience, managed care experience, and Medicaid experience are preferred.

Responsibilities

The Medical Director will ensure timely and consistent responses to members and providers regarding precertification, concurrent review, and appeal requests, primarily focusing on Utilization Management, including prior authorization, precertification, and concurrent review. This role involves managing inpatient and outpatient cases, acute and post-acute care, conducting peer-to-peer calls, and handling first-level appeals. The Medical Director will also participate in a rotating on-call schedule for weekend and holiday coverage and may support other health plans as needed.

Skills

Medical Director

Utilization Management

Prior Authorization

Precertification

Concurrent Review

Appeals

Peer to Peer Calls

Texas State Medical License

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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