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Medical Director
CVS Health. Oversee utilization review for health systems in the New England Region .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization review and quality evaluation within health systems, with a focus on inpatient hospitalizations and prior authorizations. Holds an active medical license and board certification, with a strong understanding of the New England healthcare market and member needs.
Highest-signal resume keywords
Utilization ReviewMedical LicenseBoard CertificationClinical Program DevelopmentHealth Care Delivery System Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewQuality EvaluationPrior AuthorizationConcurrent ReviewsPeer to Peer CallsFirst Level AppealsPost-Graduate Direct Patient CareClinical PracticeHealth Care Industry ExperienceMedical Management Programs
Soft Skills
Timely CommunicationCollaborationProblem Solving
Tools & Technologies
Microsoft OutlookMicrosoft Teams
Certifications & Qualifications
M.D.D.O.Board Certification in ABMS or AOA Specialty
Industry Keywords
Health SystemsNew England RegionValue-Based CareHealth PlanPhysician Advisor
About the role
Key responsibilities & impact- Oversee utilization review for health systems in the New England Region
- Perform and oversee utilization review and quality evaluation of inpatient hospitalizations, prior authorizations, and appeals
- 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
- Handle Prior Authorization, Pre Certification, Concurrent Reviews, Peer to Peer Calls, First Level Appeals, Special Projects, and Committee participation when needed
- Learn about the New England market, including hospitals, outpatient networks, and value-based care relationships
Requirements
What you’ll need- Two (2) or more years of experience in Health Care Delivery System, e.g., Clinical Practice and Health Care Industry
- Active and current medical license without encumbrances
- M.D. or D.O.
- Active and Current Board Certification in an ABMS or AOA recognized specialty
- Post-graduate direct patient care experience
- Experience with technology such as Microsoft Outlook and Teams
- Ability to obtain a New England state medical license within a reasonable timeframe, if not already licensed
- Previous UM experience with a Health Plan / Payor preferred
- Previous UM experience as a Physician Advisor in a Health / Hospital system preferred
- Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine preferred
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