Medical Director (Medical Policy Ops-DRG)

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, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company? This is a remote "Work at Home" position that can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent‑focused medical care with a focus on clinical and payment policy. Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential. Role This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas. In this role you will: Participate on work groups as a clinical subject‑matter expert to identify and promote opportunities to improve the quality and efficiency of health care services. Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services. Be a subject‑matter expert, internal consultant and payment‑policy contributor. Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company. Work collaboratively with functional areas. Primary Responsibilities Support the appeal process, clinical claim review process, pre‑certification, and predetermination of covered benefits in the Commercial and Medicare environment. Be a subject‑matter expert in DRG reviews and ICD‑10 code selection; provide coding guidelines for CPT, HCPCS, and ICD‑10 codes. Required Qualifications 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. M.D. or D.O., Board Certification in an ABMS‑recognized specialty including post‑graduate direct patient care experience. Preferred Qualifications Health plan/payor experience. Foundational baseline skills in Medicine, Health Policy, Coding (HCPCS / CPT), Clinical Policy, Reimbursement and Health Care Systems. Experience with DRG reviews. Strong communication skills both written and verbal. Education M.D. or D.O., Board Certification in an ABMS‑recognized specialty including post‑graduate direct patient care experience. 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. 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 We anticipate the application window for this opening will close on: 04/24/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr CVS Health