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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)

<h3> Position Summary </h3> Are you an experienced, passionate pioneer in technology who wants to work in a collaborative environment? As an experienced Epic Certified Professional Billing Expected Reimbursement Contracts Specialist you will have the ability to share new ideas and collaborate on projects as a consultant without the extensive demands of travel. If so, consider an opportunity with Deloitte under our Project Delivery Talent Model. Project Delivery Model (PDM) is a talent model that is tailored specifically for long-term, onsite client service delivery. Work you’ll do/Responsibilities <ul> <li>As a Consultant at Deloitte Consulting, you will be responsible for individually contributing to your work / mentor junior team members along with liaising with onsite/offshore teams to understand the functional requirements.</li> <li>Working on Billing and Contracts Reimbursement configuration and builds by maintaining industry and client standards ensuring build quality and timeline adherence as well as debugging and resolving any issues/defects.</li> <li>Participate in the daily calls / scrum meetings with respect to deliverables and build the weekly status reports to be reviewed with leadership. </li> <li>Resolve issues or incidents reported by end users and escalate any quality issues or risks with team leads/scrum masters/project leaders. </li> <li>This position has responsibility within all phases of patient access application support and optimization including design, build, test, and maintenance of the application</li> <li>This role provides outstanding client service and contributes to the organization’s mission of utilizing information technology to improve patient care</li> <li>Troubleshoot problems and address questions from users and provide on-call support on a rotating basis.</li> <li>Make recommendations, review and test changes, enhancements, and each new release as assigned.</li> <li>Communicate regularly with Engagement Managers (Directors), project team members, and representatives from various functional and / or technical teams, including escalating any matters that require additional attention and consideration from engagement management</li> </ul> The Team Our Core Technology Operations (CTO) team offers differentiated operate services for our clients with solutions to help organizations scale and optimize critical business operations, drive speed to outcome, deliver business transformation, and build resilience in an uncertain future. Qualifications Required <ul> <li>Epic Certification: Must possess current Epic Professional Billing Expected Reimbursement Contracts certification</li> <li>5+ years of experience in IT systems administration, with at least 2 years specifically working with Epic systems.</li> <li>Prior experience working in the Healthcare Industry</li> <li>Bachelor's degree, preferably in Computer Science, Information Technology, Computer Engineering, or related IT discipline; or equivalent experience</li> <li>Limited immigration sponsorship may be available</li> <li>Remote work with the ability to travel 10%, on average, based on the work you do and the clients and industries/sectors you serve. Also, provide on-call support on a rotating basis.</li> </ul> Preferred <ul> <li>Epic Certification: Current Epic Resolute Professional Billing/Epic Resolute Hospital Billing certification</li> <li>Previous Consulting experience</li> <li>Analytical/ decision making responsibilities</li> <li>Analytical ability to manage multiple projects and prioritize tasks into manageable work products</li> <li>Can operate independently or with minimum supervision</li> <li>Excellent written and communication skills</li> <li>Ability to deliver technical demonstrations</li> </ul> Information for applicants with a need for accommodation: <a href="https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html" target="_blank">https://www2.deloitte.com/us/en/pages/careers/articles/join-deloitte-assistance-for-disabled-applicants.html</a> Recruiting tips From developing a stand out resume to putting your best foot forward in the interview, we want you to feel prepared and confident as you explore opportunities at Deloitte. <a href="https://www2.deloitte.com/us/en/pages/careers/topics/recruiting-tips.html" target="_blank">Check out recruiting tips from Deloitte recruiters.</a> Benefits At Deloitte, we know that great people make a great organization. We value our people and offer employees a broad range of benefits. <a href="https://www2.deloitte.com/us/en/pages/careers/articles/life-at-deloitte-benefits-and-rewards-usdc.html" target="_blank">Learn more about what working at Deloitte can mean for you.</a> Our people and culture Our inclusive culture empowers our people to be who they are, contribute their unique perspectives, and make a difference individually and collectively. It enables us to leverage different ideas and perspectives, and bring more creativity and innovation to help solve our clients' most complex challenges. This makes Deloitte one of the most rewarding places to work. Our purpose Deloitte’s purpose is to make an impact that matters for our people, clients, and communities. At Deloitte, purpose is synonymous with how we work every day. It defines who we are. Our purpose comes through in our work with clients that enables impact and value in their organizations, as well as through our own investments, commitments, and actions across areas that help drive positive outcomes for our communities. <a href="https://www2.deloitte.com/us/en/pages/about-deloitte/articles/purpose-at-deloitte-us.html" target="_blank">Learn more.</a> Professional development From entry-level employees to senior leaders, we believe there’s always room to learn. We offer opportunities to build new skills, take on leadership opportunities and connect and grow through mentorship. From on-the-job learning experiences to formal development programs, our professionals have a variety of opportunities to continue to grow throughout their career.

2 Operations Jobs in Pittsburgh, PA, USA