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At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryAetna, 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 and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy &amp; 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. This Medical Director provides subject matter expertise to provide clinical support and business direction in these areas. 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. The Primary Responsibilities of the Medical Director include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. 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 and internal consultant and payment policy contributor subject matter expertise and internal consultant. ◾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 the functional areas. 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. * 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 experiencePay RangeThe 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 04/30/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CVSHealth

Medical Director (Medical Policy & Operations)

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position SummaryCollaborates with the plan sponsor implementation team to gather and analyze client requirements, assist in developing implementation plans, and work with internal departments to ensure the successful execution of implementation projects. Interacts directly with plan sponsors, addresses inquiries, and provides guidance during the implementation process, contributing to the overall success of plan sponsor onboarding. What you will do<ul> <li>Facilitates and oversees the management of Renewal process and programs, ensuring successful implementation, execution, and delivery.</li> <li>Manages Daily Case Calls to review complex cases in Salesforce</li> <li>Facilitates mutually beneficial relationships with members of Client Management, serving as a primary point of contact throughout the Renewal process.</li> <li>Coaches team members with training and education sessions to ensure successful adoption of Renewal process and case requests.</li> <li>Confers with internal and external stakeholders to gather and analyze requirements, identify potential risks, and develop mitigation strategies.</li> <li>Defines regular status updates to stakeholders, addressing and escalating any concerns or issues that may arise, for swift resolution.</li> <li>Determines process improvements and best practices to enhance the efficiency and effectiveness of the Renewal process.</li> <li>Delivers leadership and mentorship to the implementation team, fostering a collaborative and high-performing work environment.</li> </ul> For this role you will need Minimum Requirements<ul> <li>5 to7 years of Reporting experience</li> <li>3 to 5 years’ experience with Salesforce software and the insurance renewal process</li> <li>3 to 5 years health insurance- group based plan benefits experience</li> <li>Adept at problem solving and decision-making skills</li> <li>Adept at growth mindset (agility and developing yourself and others) skills</li> <li>Adept at execution and delivery (planning, delivering, and supporting) skills</li> </ul>Preferred Requirements<ul> <li>DG experience</li> <li>Tableau experience</li> </ul> Education<ul><li>Bachelor's degree preferred/specialized training/relevant professional qualification.</li></ul>Anticipated Weekly Hours40Time TypeFull timePay RangeThe typical pay range for this role is:$54,300.00 - $159,120.00This 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 06/29/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Renewals Operations Reporting Manager

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position Summary We are seeking a highly skilled and motivated AI Project Manager to join our team. This role is pivotal in managing the delivery of AI projects, working closely with matrixed business SMEs and technical teams. The ideal candidate will have a strong background in project management, AI, data management, and business testing, with the ability to oversee project timelines, budgets, and deliverables effectively. Additionally, this role will be key in helping business partners identify the art of the possible when it comes to AI.Key Responsibilities include:Manage the Delivery of AI Projects:<ul> <li>Collaborate with matrixed business SMEs and technical teams to ensure successful delivery of AI projects</li> <li>Define project scope, objectives, and deliverables in alignment with business goals</li> <li>Develop detailed project plans, including timelines, budgets, and resource allocation</li> <li>Identify and manage project risks, issues, and dependencies</li> <li>Oversee business testing to ensure the effectiveness and accuracy of AI solutions</li> <li>Act as a liaison with the DDAT team to ensure alignment and integration</li> <li>Monitor and evaluate the effectiveness of data management strategies and make necessary adjustments</li> </ul>Identify the Art of the Possible:<ul> <li>Work closely with business partners to explore and identify innovative AI opportunities</li> <li>Provide insights and recommendations on how AI can be leveraged to achieve business objectives</li> <li>Facilitate workshops and brainstorming sessions to generate AI use case ideas</li> <li>Stay updated on the latest AI trends and technologies to inform business partners of new possibilities</li> </ul> Required Qualifications<ul> <li>7+ years of experience in project management, data management, and business testing</li> <li>Understanding of AI persona development and implementation</li> <li>Solid understanding of AI technologies and their applications in business</li> <li>Excellent project management skills with the ability to manage multiple priorities</li> <li>Strong analytical and problem-solving skills</li> <li>Excellent communication and collaboration skills</li> <li>Ability to work effectively in a matrixed environment</li> <li>Experience with project management tools and methodologies</li> </ul> Preferred Qualifications<ul> <li>Experience with data management tools and technologies</li> <li>Knowledge of change management principles and practices</li> <li>Familiarity with DDAT frameworks and methodologies</li> </ul> Education<ul><li>Bachelor’s degree in Computer Science, Data Science, Business Administration, or a related field</li></ul>Pay RangeThe typical pay range for this role is:$67,900.00 - $182,549.00 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe 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:<ul> <li>Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li> <li>No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li> <li>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.</li> </ul>For more information, visit <a href="https://jobs.cvshealth.com/us/en/benefits" target="_blank">https://jobs.cvshealth.com/us/en/benefits</a>We anticipate the application window for this opening will close on: 05/10/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

3 Operations Jobs in Baxley, GA 31513, USA