About the position
CVS Health, a Fortune 6 company, has an outstanding opportunity for a Medical Director (Medical Affairs). This is a remote based, work from home opportunity. The Medical Affairs department provides clinical business support to the entire enterprise and provides clinical oversight and mentorship for CVS Health clinical programs, PBM Clinical Quality activities, consultative support to the P&T process, formulary development, drug information services and pipeline activities, and provision of clinical leadership to various internal departments (e.g., specialty pharmacy services, clinical product development, Enterprise Analytics, Compliance, Legal, Accreditation) and clients. The Medical Director (Medical Affairs) will report into the Medical Affairs Department and is responsible for clinical support and consultative activities across the PBM. In this role you may provide consultative clinical support to Account Management in support of Key Clients as assigned. The Medical Director transacts Utilization Management UM activities (prior authorization and appeals) and responds to prescriber inquiries related to UM transactions and more generally related to CVS Health coverage policies. Medical Directors at CVS Health are encouraged to model the highest levels of clinical integrity, knowledge and cross functional thinking and decision making. Medical Directors represent the clinical decision making and professional thought process of the prescriber as a partner across the enterprise's decisions and planning. Each Director is responsible for providing oversight of a portion of CVS Health's clinical programs and commercial client program support. Will share in reviews of utilization management (PA) criteria and clinical policy revisions/reviews. Directors will spend a portion of most days completing assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients, governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate. Medical Directors will participate in inter-rater review activities and other quality oversight processes for internal Director UM decisions. If specifically assigned to one business segment (i.e., Medicare clients), each director will become sufficiently skilled in various UM programs to support other segments (including commercial and Medicaid) on evening and weekend coverage. In this role you'll perform a share of special clinical investigations and research as requested by the Senior Medical Director, Medical Affairs. These projects can include brief reviews of published literature around specific pharmaceutical questions or more in-depth projects requiring collaboration with pharmacists within Medical Affairs and in business units outside of the Department.
Responsibilities
- Provide clinical support and consultative activities across the PBM.
- Transact Utilization Management UM activities (prior authorization and appeals).
- Respond to prescriber inquiries related to UM transactions and CVS Health coverage policies.
- Model the highest levels of clinical integrity, knowledge and cross functional thinking.
- Provide oversight of CVS Health's clinical programs and commercial client program support.
- Complete assigned medication utilization reviews (PA) and/or medical necessity appeals.
- Participate in inter-rater review activities and quality oversight processes.
- Perform special clinical investigations and research as requested.
Requirements
- Family Medicine or Internal Medicine Board Certification.
- Minimum of 5 years clinical experience in direct patient care.
- 2 or more years proven experience in clinical outcomes, with a solid understanding of medical statistics, regulatory agencies, and analytic programs.
- Unrestricted license to practice medicine in the state in which the candidate is located.
Nice-to-haves
- Combination of five years of management and/or clinical experience in a managed care environment and health administration.
- ABMS or AOA Board Certified in a recognized medical specialty, preferably in a Primary Care field.
- Master's Degree in Public Health Administration or MBA preferred.
- UM/QA certification desired.
- Proficiency in MS Office Suite.
Benefits
- Affordable medical plan options.
- 401(k) plan (including matching company contributions).
- Employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs.
- Confidential counseling and financial coaching.
- Paid time off.
- Flexible work schedules.
- Family leave.
- Dependent care resources.
- Colleague assistance programs.
- Tuition assistance.
- Retiree medical access.
