• Provides oversight for medical policy implementation, supports the Medical Management staff to ensure timely and consistent responses to members and providers.
• Oversees utilization review/quality assurance, directing case management; conducts peer-to-peers and appeal reviews.
• Provides clinical expertise and works with a multi-disciplinary team, including representatives from the state, to manage members with complex physical and behavioral health needs; participates in clinical team activities such as rounds (IDT/UM support).
• Responsible for quality improvement and population health management activities.
• Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
• Other regional and/or segment-level support duties as required.
• Active and current Kentucky medical license without encumbrances.
• M.D. or D.O., Board Certification in Pediatrics including postgraduate direct patient care experience.
• 2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and MS Office Suite applications, including Word and Excel.
CVS Health requires its Colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, or religious belief that prevents them from being vaccinated.
If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. In some states and roles, you may be required to provide proof of full vaccination before you can begin to actively work. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
If you are unable to be fully vaccinated due to disability, medical condition, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. In some states and roles, you may be required to have an approved reasonable accommodation before you can begin to actively work. If your request for an accommodation is not approved, then your employment may be terminated.
• Health plan/payor experience
• Managed Care experience
• M.D. or D.O.
• Board Certification in Pediatrics including post-graduate direct patient care experience.
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.