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Clinical Director
2 months ago
CVS Health is seeking a highly skilled Medical Director to lead our medical management programs and provide clinical expertise in support of our business objectives.
Key Responsibilities- Provide oversight for medical policy implementation and development, ensuring alignment with company goals and objectives.
- Participate in the development, implementation, and evaluation of clinical and medical programs to address member needs across the continuum of care.
- Support the Medical Management staff in ensuring timely and consistent responses to members and providers.
- Oversee utilization review and quality assurance, including predetermination reviews, prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, first-level appeals, and special projects.
- Provide clinical expertise and direct case management as needed.
- Act as a lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs.
- Active and current state medical license in either PA/WV/DE state without encumbrances.
- M.D. or D.O., Board Certification in an ABMS or AOA recognized specialty with post-graduate direct patient care experience.
- Previous UM experience with a Health Plan/Payor is preferred.
