Medical Director - Regulated Medicare Appeals, CVS Health

Medical Director - Regulated Medicare Appeals

CVS Health

Location:

United States, Work At Home

Category:

Health and Beauty

Contract Type:

Employment contract

Salary:

174070.00 - 374920.00 USD / Year

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Job Description:

As the nation’s leading health solutions company, CVS Health is hiring for a Medical Director role to oversee Regulated Medicare Appeals. The candidate will work remotely across the U.S. and perform tasks such as supervising Medicare appeals, supporting nurses and pharmacists, and ensuring compliance with Medicare policies.

Job Responsibility:

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
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
Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work

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

Nice to have:

Medical Management - Medicare Complaints, Grievance & Appeals experience
Health Plan Experience Highly Preferred

What we offer:

Affordable medical plan options
a 401(k) plan (including matching company contributions)
employee stock purchase plan
no-cost wellness programs
counseling and financial coaching
paid time off
flexible work schedules
family leave
dependent care resources
tuition assistance
retiree medical access

Additional Information:

Job Posted:

March 19, 2025

Expiration:

April 30, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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