Medical Director,Utilization Management at CVS Health

Chicago, Illinois, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

At least 2 years experience providing Utilization Management services to a Medicare and/or Medicaid line of business
Excellent verbal and written communication skills
A current, clinical, unrestricted license to practice medicine in the United States (NCQA Standard)
Prior clinical leadership or supervision experience is preferred
Graduate of an accredited medical school; M.D. or D.O. Degree is required (NCQA Standard)
3-5 years of clinical practice in a primary care setting
Deep understanding of managed care, risk arrangements, capitation, peer review

Responsibilities

Lead and manage the Utilization Management team, providing guidance, training, and support
Support recruiting, hiring, and retaining skilled UM clinical staff, fostering a collaborative and high-performance work environment
Conduct regular performance evaluations, offering feedback, coaching, and professional development opportunities
Develop and implement UM policies and procedures in compliance with regulatory requirements and industry standards in conjunction with other UM Leadership
Monitor and evaluate the performance of the UM team, ensuring efficiency and effectiveness in all UM activities
Conduct and oversee clinical reviews of medical records to determine the medical necessity and appropriateness of healthcare services
Ensure timely and accurate review of prior authorizations, concurrent reviews, and retrospective reviews
Collaborate with healthcare providers to facilitate appropriate utilization of healthcare resources
Develop and implement quality assurance programs to monitor and improve UM processes
Analyze UM data and metrics to identify trends, gaps, and areas for improvement
Implement evidence-based practices and clinical guidelines to enhance patient care and outcomes
Ensure compliance with all federal, state, and local regulations related to utilization management
Stay current with changes in healthcare regulations and standards affecting UM practices
Prepare and present reports to regulatory agencies, accrediting bodies, and internal stakeholders as required
Work closely with other departments, including Transitions, Case Management, and Care Teams, to ensure coordinated and integrated care
Communicate effectively with healthcare providers, patients, and other stakeholders regarding UM decisions and policies
Serve as a clinical resource and advisor to the UM team and other departments
Other duties as assigned

Skills

Utilization Management

Medical Necessity Review

Care Coordination

Team Leadership

Regulatory Compliance

Policy Development

Performance Evaluation

Healthcare Delivery

Staff Training

Stakeholder Collaboration

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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