Medical Director - Medicare Appeals
At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary Aetna, a CVS Health Company, a Fortune 6 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.
- *This is a remote based (work at home) based anywhere in the US.**
Responsibilities of this Medical Director role are related to Medicare Appeals.
- Direct daily work on part C appeals (both provider and member/nonparticipating providers)
- Provide direct support to appeal nurses; supervision and participation in the Second Look Review (SLR) process
- Provide direct support to the nurses
Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work
- IRE monitoring and tracking and Utilization Management Strategy support
- Collaborative work with Medicare Quality and Compliance on an ongoing basis
- Develop subject matter expertise on Medicare policy for the enterprise
- Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff
- Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency
Required Qualifications
- Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry
- Medical License (MD) or (DO)
- An Active state medical license without encumbrances
- Board Certified in ABMS or AOA Recognized Specialty
Preferred Qualifications
- Medical Management - Medicare Complaints, Grievance & Appeals experience.
- Health Plan Experience Highly Preferred
Education: MD or DO Pay Range The typical pay range for this role is: $174,070.00 - $374,920.00 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. This position also includes an award target in the company’s equity award program. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits 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: 10/31/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job