Senior Medical Director – Precertification
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Job Description
Senior Medical Director overseeing clinical operations for Medicare and other activities at CVS Health. Leading the Precertification Team and driving process improvements for quality care.
Responsibilities:
- Provides strategic direction, professional oversight, and leadership throughout the precert process and other clinical operations.
- Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.
- Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.
- Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.
- Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.
- Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.
- Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.
- Leads teams through Medicare audits and on-going audit readiness.
- Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.
- Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.
- Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.
- Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.
- Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.
Requirements:
- MD or DO with active, unrestricted license and board certification in an ABMS or AOA recognized specialty
- Minimum 5 years of direct patient care in a clinical setting
- Minimum 5 years in utilization management, precertification, or related roles
- Deep expertise in Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references
- Proven ability to interpret and apply Medicare guidelines to complex case review and decision-making
- Advanced knowledge of medical coding standards, compliance requirements, and oversight of coding practices
- Demonstrated leadership in managing teams, driving process improvement, and ensuring regulatory compliance
- Successful track record guiding teams through Medicare audits and maintaining audit readiness
- Strong interpersonal, communication, and cross-functional stakeholder management skills
- Commitment to developing talent and fostering an inclusive, high-performing team culture
Benefits:
- medical, dental, and vision coverage
- paid time off
- retirement savings options
- wellness programs
- other resources, based on eligibility
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