Medical Director - Medicare (Medical Policy & Operations)

Medical Director - Medicare (Medical Policy & Operations)

Apply for the Medical Director - Medicare (Medical Policy & Operations) position at CVS Health .

Company Overview

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, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company? This is a remote Work‑at‑Home position and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent‑focused medical care with a focus on clinical and payment policy.

Primary Responsibilities

• Support the appeal process, clinical claim review process, pre‑certification and predetermination of covered benefits in the Commercial and Medicare environment with a focus on Medicare policy.
• Participate on work groups as a clinical subject matter expert 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 effective delivery of quality care services.
• Be a subject matter expert, internal consultant and payment policy contributor.
• Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals to manage the business objectives of the company.
• Work collaboratively with the functional areas.

Required Qualifications

Preferred Qualifications

Education

Pay Range

$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.

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 :

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits .

Application Window

We anticipate the application window for this opening will close on : 12 / 15 / 2025.

EEO Statement

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Seniority Level

Director

Employment Type

Full‑time

Job Function

Health Care Provider

Industry

Hospitals and Health Care

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