Medical Director Aetna Duals Center of Excellence

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. Position Summary: The Aetna Duals Center of Excellence (COE) operates Duals Integrated Plans: Ohio, Illinois, Michigan, Virginia, Pennsylvania, and New Jersey offering a variety of physical and behavioral health programs and services to its membership. Aetna is looking for a medical director to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request. The medical director is a work-at-home position located anywhere in the US. The Medical Director will be required to work Eastern or Central Standard time 8-5. Occasional weekend/holiday call to cover urgent cases can be done from your laptop. Fundamental Components: • Utilization management - The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials. • Appeals - The medical director will perform appeals in their "base plan" and in the round robin based on "same or similar specialty" needs. • Pharmacy coverage - The medical director will perform pharmacy reviews. • The medical director will participate in and be able to lead daily rounds. Required Qualifications: Minimum 3-5 years of clinical practice experience. Two (2) + years of experience in managed care (Medicare and/or Medicaid) MD or DO; Board certification in an ABMS or AOA recognized specialty is required. Active and current state medical license without encumbrances is required. Multiple state licensure a plus. Preferred Qualifications: Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System. Licensed in or willing to obtain license in at least one state where we have an Integrated plan. Experience with managed care (Medicare and Medicaid) utilization review preferred. Education MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine) 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 our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: • Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 10/30/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job