CVS Health
Overview
Medical Director MPO (Medical Policy & Operations) at CVS Health (Aetna). This is a remote Work at Home position and can be located anywhere in the United States. Provide clinical expertise and business direction in support of medical management programs to promote high-quality, constituent-focused medical care with a focus on clinical and payment policy. Responsibilities
Support the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. Serve as a clinical subject matter expert on work groups to identify and promote opportunities to improve the quality and efficiency of health care services. Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. Proactively use data analysis to identify opportunities for quality improvement and positively influence the delivery of quality care services. Be a subject matter expert and internal consultant on payment policy and internal advisory activities. Demonstrate the ability to work within and lead teams of diverse health delivery professionals to achieve business objectives. Collaborate with functional areas to support business objectives. Required Qualifications
Five (5) or more years of experience in Health Care Delivery System (clinical practice and health care industry). Active and current state medical license without encumbrances. M.D. or D.O., Board Certification in an ABMS-recognized specialty including post-graduate direct patient care experience. Preferred Qualifications
Health plan/payor experience. Foundational skills in Medicine, Health Policy, Coding (HCPCS / CPT), Clinical Policy, Reimbursement and Health Care Systems. Strong communication skills both written and verbal. Education
M.D. or D.O., Board Certification in an ABMS-recognized specialty including post-graduate direct patient care experience. Pay and Benefits
The typical pay range for this role is $174,070.00 - $374,920.00. This base pay range applies to positions within this job grade. The actual base salary offer depends on factors including experience, education, geography and other relevant factors. This position is eligible for CVS Health bonus, commission or short-term incentive programs in addition to base pay, and may include an equity award. Our benefits include affordable medical plan options, a 401(k) plan (including company match), an employee stock purchase plan, wellness and other confidential support programs, paid time off, flexible work schedules, family leave, and more depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/30/2025. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Job Details
Seniority level: Director Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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Medical Director MPO (Medical Policy & Operations) at CVS Health (Aetna). This is a remote Work at Home position and can be located anywhere in the United States. Provide clinical expertise and business direction in support of medical management programs to promote high-quality, constituent-focused medical care with a focus on clinical and payment policy. Responsibilities
Support the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. Serve as a clinical subject matter expert on work groups to identify and promote opportunities to improve the quality and efficiency of health care services. Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. Proactively use data analysis to identify opportunities for quality improvement and positively influence the delivery of quality care services. Be a subject matter expert and internal consultant on payment policy and internal advisory activities. Demonstrate the ability to work within and lead teams of diverse health delivery professionals to achieve business objectives. Collaborate with functional areas to support business objectives. Required Qualifications
Five (5) or more years of experience in Health Care Delivery System (clinical practice and health care industry). Active and current state medical license without encumbrances. M.D. or D.O., Board Certification in an ABMS-recognized specialty including post-graduate direct patient care experience. Preferred Qualifications
Health plan/payor experience. Foundational skills in Medicine, Health Policy, Coding (HCPCS / CPT), Clinical Policy, Reimbursement and Health Care Systems. Strong communication skills both written and verbal. Education
M.D. or D.O., Board Certification in an ABMS-recognized specialty including post-graduate direct patient care experience. Pay and Benefits
The typical pay range for this role is $174,070.00 - $374,920.00. This base pay range applies to positions within this job grade. The actual base salary offer depends on factors including experience, education, geography and other relevant factors. This position is eligible for CVS Health bonus, commission or short-term incentive programs in addition to base pay, and may include an equity award. Our benefits include affordable medical plan options, a 401(k) plan (including company match), an employee stock purchase plan, wellness and other confidential support programs, paid time off, flexible work schedules, family leave, and more depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 09/30/2025. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Job Details
Seniority level: Director Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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