Sr. Clinical Solutions MD - Medicare Duals Behavioral Health

CVS Health



Columbus, OH

Why you should apply for a job to CVS Health:

  • 62% say women are treated fairly and equally to men
  • 52% say the CEO supports gender diversity
  • Ratings are based on anonymous reviews by Fairygodboss members.


    Position summary

    etitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.

    Aetna Medicare Duals Center of Excellence is looking for a board-certified adult psychiatrist with at least five years' experience in mental health and substance use disorder services for this work-from-home position. This person will oversee and be responsible for all behavioral health activities in the health plans, including oversight of coordination activities with the federal and state agencies, and shall work closely with the other functional area leaders and other medical directors to ensure the delivery of holistic and integrated person-centered care.

    The Medical Director will be responsible for provider education regarding best clinical practices, utilization management, care management, claims adjudication, pharmacy utilization, quality improvement, grievance and appeals, policies and procedures, and responsible health care expenditure to improve clinical outcomes. They will help lead continued quality improvement and evolution of the delivery system in the assigned duals markets, including working collaboratively with providers to encourage development of new and more community-based types of care, and better integrating behavioral health, physical health, and social determinants of health. The medical director will develop, implement, support, and promote Medical Affairs strategies, tactics, policies, and programs that drive the delivery of quality behavioral healthcare to establish competitive business advantage for Aetna.

    This is a Work from Home Remote Position with travel as needed but most likely less than 10% Travel. Preferences for NY, NJ, VA, OH, MI and IL licenses.

    Primary Job Duties & Responsibilities

    • Collaborates with health plan Sr Leadership to identify, develop, implement, and evaluate the effectiveness of strategic initiatives including trends, policies and programs, designed to drive the delivery of high value healthcare supporting a sustainable competitive business advantage for members.

    • Ensures plan makes timely medical decisions, including after-hours consultation as needed.

    • Leads all major clinical, population health management, and quality improvement components of the aligned plan.

    • Develops, implements and interprets medical policies and procedures, including service authorization, claims review, discharge planning, and medical reviews performed through the aligned plan's grievance and appeal system.

    • Leads the administration of all medical management activities of the aligned Plan.

    • Serves as the chair or co-chair of the Utilization Management committee and of the aligned plan's internal quality improvement committee.

    • Plays a lead role in monitoring the overall safety of members with complex and or comorbid medical conditions.

    • Coordinates with the MCOs' care management staff and providers on medical services not included in the aligned plan's service array.

    • Serves as a key clinical lead in developing and implementing evidence-based clinical policies and practices.

    • Participates in regulatory/ accreditation reviews.

    • Works with MCO's clinical leadership as needed for integration of all health care needs and services for aligned plan's members.

    Required Qualifications

    Five (5) or more years of experience in Behavioral Health in the healthcare delivery system, e.g., clinical practice and health care industry

    • Three (3) or more years of experience in Managed Care

    • Board Certification in ABMS recognized specialty of Adult Psychiatry

    • Active and current state medical license without encumbrances

    • M.D. or D.O.

    • Post graduate direct patient care experience

    • Strong strategic thinking and collaborative skills to drive innovation and integration within behavioral health.

    • Independently motivated and capable of researching and adjudicating Medicare and Medicaid benefit and coverage decisions.

    • Strong communication skills both written and verbal.

    M.D. or D.O.

    Pay Range

    The typical pay range for this role is:

    $184,112.50 - $396,600.00

    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.

    In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

    For more detailed information on available benefits, please visit

    We anticipate the application window for this opening will close on: 07/31/2024

    Why you should apply for a job to CVS Health:

  • 62% say women are treated fairly and equally to men
  • 52% say the CEO supports gender diversity
  • Ratings are based on anonymous reviews by Fairygodboss members.