Executive Medical Director, Commercial

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

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.

Aetna, a CVS Health company, is leading the industry in service of our members, providers, and plan sponsors across the country. Aetna Medical Affairs is a clinically-focused center of excellence working in close collaboration with all business functions and cross-enterprise partners, to ensure quality care for our members and best-in-class operating models. We are in search of an Executive Medical Director, Commercial who will provide clinical leadership for medical management activities in support of plan sponsor clients across the country. This role will serve as an essential clinical leader in developing, executing, and optimizing strategies to manage care for member populations, optimizing quality, cost of care, and member and provider experience. They will lead a team of Senior Medical Directors and Medical Directors to implement medical management programs and policies. They will work cross-functionally to ensure business and plan sponsor priorities are met, and will intersect with business leaders and plan sponsor clients, in service of group contracts. This role will be expected to travel approximately 10% of the time, and provide some weekend "on call" coverage as necessary. Join us in this exciting opportunity as we continue to differentiate Aetna clinical support and ensure quality care for our members.

Required Qualifications

Primary Job Duties & Responsibilities

• Lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality, cost, and outcomes.

• Direct the utilization review process and oversee the quality of utilization determinations, including case reviews, peer to peer provider discussions, and appeals.

• Ensure compliance with clinical goals through monitoring of care management performance.

• Oversee application of medical policies to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of medical management staff.

• Recommend changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.

• Develop, implement, and interpret medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.

• Lead clinical staff in the coordination of quality care. Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.

• Analyze policy/procedure/workflows on case management and utilization management for redesign and efficiency opportunities.

• Act as lead clinical liaison to select plan sponsors including reviewing clinical trends, exploring new clinical strategies, handling escalations, and supporting sales and renewal activities as needed. Support and train SMDs and MDs on such activities.

• Identify and advance new affordability initiatives for the Commercial line of business, not limited to medical policy and utilization review activities.

• Monitor KPIs and trends to understand value and opportunities and expand Aetna's medical management programs to address member needs across the continuum of care.

• Provide clinical support for UM/CM/Appeals complex or escalated cases as appropriate.

• Participate in an on‑call rotation, including occasional weekend coverage.

Required Experience & Qualifications

• Five (5) or more years of experience in clinical practice

• Five (5) or more years admi