Medical Director - Medicare Appeals

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 and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process
• Provide direct support to the Quality Review 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
• 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 Medical License (MD) or (DO)