Medical Director - Medicare Appeals

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, 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. Position Summary Aetna, a CVS Health Company, a Fortune 6 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. **This is a remote based (work at home) based anywhere in the US.** 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; supervision and participation in the Second Look Review (SLR) process * 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 * Collaborative work with Medicare Quality and Compliance on an ongoing basis * 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 Required Qualifications * 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 or AOA Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly Preferred Education: MD or DO Pay Range The typical pay range for this role is: $174,070.00 - $374,920.00 This 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments . We anticipate the application window for this opening will close on: 09/25/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.