Senior Medical Director Medicaid

Position Summary Aetna, a CVS Health Company, seeks a Senior Medical Director to lead the Northeast Medicaid region. This role oversees medical management activities across Maryland, New Jersey, New York, Pennsylvania, and Virginia. Responsibilities Lead, develop, direct and implement clinical and non‑clinical activities impacting health care quality, cost, and outcomes. Direct the utilization review process and oversee the quality of utilization determinations. Ensure compliance with clinical goals through monitoring care management performance. Responsible for overall medical policies of the unit to ensure cost‑effective medical care and manage day‑to‑day medical management staff. Recommend changes to managed care review guidelines, clinical criteria, and treatment protocols. Develop, implement, and interpret medical policy including medical necessity criteria and clinical practice guidelines. Lead clinical staff in quality care coordination and provide clinical expertise in medical management programs. Act as lead business and clinical liaison to network providers and facilities for program execution. Review predetermination and claim determinations, providing clinical, coding, and reimbursement expertise. Expand Aetna's medical management programs across the continuum of care. Required Qualifications Five (5) or more years of clinical practice experience. Five (5) or more years of administrative experience in health care/managed care. M.D. or D.O. with active board certification in an ABMS or AOA recognized specialty and post‑graduate direct patient care experience. Current and active state medical license without encumbrances. Preferred Experience Previous utilization management experience with a health plan or hospital system. Prior Medicaid experience. Management of a team. Familiarity with CMS and/or MCG guidelines and state specific Medicaid contracts. Key Deliverables and Expectations Participate in Executive Director and Utilization Management meetings as appropriate, and maintain excellent communication skills with clinicians, medical directors, and providers. Collaborate strategically to identify scorable action items in Medicaid and complete other assigned projects and tasks. Education M.D. or D.O. with active board certification in an ABMS or AOA recognized specialty and post‑graduate direct patient care experience. Pay Range The typical pay range for this role is $184,112.00 – $396,550.00, reflecting base pay for the relevant job grade. The actual offer will depend on experience, education, geography, and other factors. The position includes bonus, commission, short‑term incentive, and equity award eligibility. Benefits This full‑time position offers a comprehensive benefits package, including medical, dental, and vision coverage; paid time off; retirement savings options; wellness programs; and other resources, based on eligibility. Equal Opportunity Employment Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr 9025 CVS Shared Services Resources LLC