Medical Director - Medicare Appeals

2 days ago

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CVS Health

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Retail • Pharmacy Benefits Management • Health Insurance • Health Care • Pharmacy

10,000+

Description

• Responsibilities of this Medical Director role are related to Medicare Appeals. • Direct daily work on part C appeals (both provider and member/nonparticipating providers). • Provide direct support to appeal nurses and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process. • Provide direct support to the Quality Review nurses. • Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work. • IRE monitoring and tracking and Utilization Management Strategy support. • Develop subject matter expertise on Medicare policy for the enterprise. • Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff. • Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency.

Requirements

• Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry. • Medical License (MD) or (DO). • An Active state medical license without encumbrances. • Board Certified in ABMS Recognized Specialty. • Medical Management - Medicare Complaints, Grievance & Appeals experience preferred. • Health Plan Experience highly preferred.

Benefits

• The Company offers a full range of medical, dental, and vision benefits. • Eligible employees may enroll in the Company’s 401(k) retirement savings plan. • An Employee Stock Purchase Plan is also available for eligible employees. • The Company provides a fully-paid term life insurance plan to eligible employees. • Short-term and long term disability benefits are provided. • CVS Health offers numerous well-being programs, education assistance, free development courses, and a CVS store discount. • Discount programs with participating partners are available. • Employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays.