Medical Director - Commercial

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health(R), you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.## Aetna, a CVS Health 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. ****In this role you will:***** ## Provide oversight for medical policy implementation.* ## Participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.* ## Support the Medical Management staff ensuring timely and consistent responses to members and providers.## ## **As a Medical Director you will:*** ## Focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews and reviews of claim determinations.* ## This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.* ## The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary.* ## In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.* ## The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.## ****## ## **Required Qualifications:**## \*2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. \*Active and current medical license without encumbrances \*M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.## **Preferred Qualifications:**## **\***Five or more years of direct patient care experience## \*Preferred licensed in TX, CA, or FL## \*Previous UM experience with a Health plan/payor experience. \*Electronic medical systems/record experience \*Managed Care experience## \*Board certification in Internal Medicine, Family Medicine, Emergency Medicine, or Med/PM&R## ## **Education**## \*Active and current state medical license without encumbrances \*M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience## **Pay Range**The typical pay range for this role is:$174,070.00 - $374,920.00This 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, visitWe anticipate the application window for this opening will close on: 04/30/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr