Medical Director – Medical Policy Ops, DRG
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Job Description
Medical Director providing clinical expertise and business direction within CVS Health. Responsible for medical management program support and quality improvement.
Responsibilities:
- Responsible for providing clinical expertise and business direction in support of medical management programs.
- Promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy.
- Support the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits.
- Be a subject matter expert in DRG reviews and ICD-10 code selection.
- Proactively use data analysis to identify opportunities for quality improvement.
Requirements:
- Five (5) 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 an ABMS recognized specialty including post-graduate direct patient care experience
- Health plan/payor experience.
- Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.
- Experience with DRG reviews.
Benefits:
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
- Many other benefits depending on eligibility
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