Medical Director - Claims Management
HumanaSalary not specified
Not SpecifiedCompensation
N/AExperience Level
N/AJob Type
Not SpecifiedVisa
N/AIndustries
Requirements
- 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry
- Active and current state medical license without encumbrances
- M.D. or D.O., Board Certification in Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically
Responsibilities
- Expands Aetna's medical management programs to address member needs across the continuum of care
- Supports the Medical Management staff ensuring timely and consistent responses to members and providers
- Leads all aspects of utilization review/quality assurance, directing case management
- Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities
- Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams
- Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise, using multiple computer based applications
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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