Medical Director - Medicaid (IL)

Illinois, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

Candidates must possess an M.D. or D.O. degree, hold an unrestricted Illinois state medical license, and be board-certified in an ABMS or AOA recognized specialty, preferably Family Medicine or Internal Medicine/Pediatrics. A minimum of five years of direct patient care experience is required, with prior utilization management experience at a health plan or as a Physician Advisor being a plus. Preferred qualifications include Illinois residency, health plan/payor utilization management/review experience, managed care experience, and Medicaid experience.

Responsibilities

The Utilization Management Medical Director will ensure timely and consistent responses to members and providers regarding precertification, concurrent review, and appeal requests, primarily supporting the Aetna Illinois Medicaid plan. This role involves managing utilization, including prior authorization and concurrent review for various services, and participating in an on-call rotation for weekend and holiday coverage. The position supports a centralized team across multiple states and may occasionally require support for other regions.

Skills

Utilization Management

Prior Authorization

Medical Director

Patient Care

Illinois Medical License

Appeals Review

State Fair Hearings

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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