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CVS HealthCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical expertise and leadership in medical policy implementation, utilization review, and medical management programs. Possesses strong capabilities in overseeing clinical operations and providing direction to medical management staff and network providers.
Highest-signal resume keywords
Medical Policy ImplementationUtilization ReviewClinical ExpertiseActive Medical LicenseBoard Certification
About the role
Key responsibilities & impact- Provide oversight for medical policy implementation
- Participate in the development, implementation, and evaluation of clinical / medical programs
- Expand Aetna's medical management programs to address member needs across the continuum of care
- Support Medical Management staff in providing timely and consistent responses to members and providers
- Oversee utilization review and quality assurance
- Perform predetermination reviews and reviews of claim determinations
- Conduct prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, and first-level appeals
- Participate in special projects and committees as needed
- Provide clinical, coding, and reimbursement expertise
- Direct case management when necessary
- Provide clinical expertise and business direction for medical management programs through clinical team activities
- Act as lead business and clinical liaison to network providers and facilities
Requirements
What you’ll need- Five (5) or more years of experience in Health Care Delivery System, e.g., Clinical Practice and Health Care Industry
- Active and current state medical license without encumbrances (FL preferred)
- M.D. or D.O.
- Board Certification in an ABMS or AOA recognized specialty
- Post-graduate direct patient care experience
- Previous UM experience with a Health Plan / Payor preferred
- Can be licensed anywhere in the United States
Benefits
Comp & perks- CVS Health bonus, commission or short-term incentive program
- Award target in the company’s equity award program
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Program DevelopmentPrior AuthorizationPre-CertificationConcurrent ReviewsPeer-To-Peer CallsFirst-Level AppealsCase ManagementCoding ExpertiseReimbursement ExpertiseQuality Assurance
Soft Skills
LeadershipCommunicationCollaborationProblem-SolvingInterpersonal Skills
Certifications & Qualifications
M.D.D.O.Board Certification
Industry Keywords
Health Care Delivery SystemClinical PracticeHealth Care IndustryMedical Management ProgramsHealth PlanPayor