Medical Director, Behavioral Health - SIU

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, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer‑focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a remote based (work from home) full‑time position and can be based anywhere in the United States. Responsibilities Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases. Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse. Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions. Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna’s approach to fighting fraud. Maintains open communication with constituents within the company. Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse. Researches and prepares cases for clinical and legal review. Documents all appropriate information related to medical record review determinations. Represents Aetna as a witness in court actions, as required, and as approved by Legal. Is responsible for Peer‑to‑Peer Reviews of SIU related claims in states that mandate such review. Exhibits behaviors outlined in Employee Competencies. Provides testimony during civil and criminal proceedings and may need to travel as required. Required Qualifications Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice). Board Certified Psychiatrist (not “Board Eligible”) with an active and unencumbered license to practice medicine. Knowledge of pertinent policies and procedures related to claims payment of healthcare related services. Education: Active and current state medical license(s) without encumbrances – M.D. or D.O., Board Certification in psychiatry, including 5 years of post‑graduate direct patient care experience. Preferred Qualifications Two years’ experience within the health care industry / knowledge of CPT and HCPCS coding guidelines and principles. Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to company, state, federal and industry standard coding principles and guidelines. Psychiatric experience in providing clinical guidance and input in the business analytic building process. Child and Adolescent Psychiatrist. Pay Range The typical pay range for this role is: $174,070.00 – $374,920.00. Great benefits for great people This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources based on eligibility. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr Capacity Path