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Medical Director - Medicare Appeals
Location
United States + 1 moreAll locations: United States | Canada
Posted
104 days ago
Salary
$174K - $374K / year
No structured requirement data.
Job Description
Medical Director - Medicare Appeals
CVS Health
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, a Fortune 6 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 at home) based anywhere in the US.** Responsibilities of this Medical Director role are related to Medicare Appeals: * Direct daily work on part C appeals (both provider and member/nonparticipating providers). * Provide direct support to appeal nurses and dedicated Medicare part D pharmacists; supervision and participation in the Second Look Review (SLR) process * Provide direct support to the Quality Review nurses Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work * IRE monitoring and tracking and Utilization Management Strategy support * Develop subject matter expertise on Medicare policy for the enterprise * Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management Staff * Participate in ongoing initiatives to improve appeals team efficiency and clinical consistency Required Qualifications: * Two (2) or more years of experience in a Health Care Delivery System e.g., Clinical Practice or Health Care Industry * Medical License (MD) or (DO) * An Active state medical license without encumbrances * Board Certified in ABMS or AOA Recognized Specialty Preferred Qualifications * Medical Management - Medicare Complaints, Grievance & Appeals experience. * Health Plan Experience Highly Preferred Education * Medical License (MD) or (DO) Pay Range The 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 people We 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: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - 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. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/31/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
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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, a Fortune 6 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. Practice Spine Surgery....From Your Home! Aetna, a CVS Health Company, is hiring physicians that are board certified in Orthopedic Spine or Neurosurgery to expand Aetna's medical management program. This is an exciting opportunity to address member needs across the continuum of care and provide clinical expertise to the spine team. The medical directors are responsible for precertification reviews of claim determinations, and provide clinical, coding and reimbursement expertise using multiple computer based applications. This is a full time position, offering a salary with yearly raises, health insurance, 401K, stock plans and other benefits and an opportunity to use your skills but work regular hours in a remote position from anywhere in the United States **This is a remote based (work at home) based anywhere in the US.** Aetna, a CVS Health Company, has an exciting opportunity for a Medical Director (Spine) that can be remote based, work from home. The Medical Director (Spine) will be a Subject Matter Expert (SME) with a background in Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Expands Aetna's medical management programs to address member needs across the continuum of care. Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Leads all aspects of utilization review/quality assurance, directing case management Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise, using multiple computer based applications. Required Qualifications * 2 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 a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Preferred Qualifications * Previous healthcare insurance experience. Education * 2 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 a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience. Pay Range The 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 people We 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: - Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. - No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. - 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. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/27/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Associate Director, Marketing - Coronary - Shockwave Medical
Johnson & Johnson Innovative MedicineAt Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions today to deliver the breakthroughs of tomorrow, and profoundly impact health for humanity.
At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions today to deliver the breakthroughs of tomorrow, and profoundly impact health for humanity. Learn more at jnj.com As guided by Our Credo, Johnson & Johnson is responsible to our employees who work with us throughout the world. We provide an inclusive work environment where each person is considered as an individual. At Johnson & Johnson, we respect the diversity and dignity of our employees and recognize their merit. Job Function: Marketing Job Sub Function: Product Management Job Category: Professional All Job Posting Locations: Santa Clara, California, United States of America Job Description: Johnson & Johnson is hiring for an Associate Director, Marketing, Coronary - Shockwave Medical to join our team. The position is FULLY REMOTE and can sit anywhere in the US. At Johnson & Johnson, we believe health is everything. Our strength in healthcare innovation empowers us to build a world where complex diseases are prevented, treated, and cured, where treatments are smarter and less invasive, and solutions are personal. Through our expertise in Innovative Medicine and MedTech, we are uniquely positioned to innovate across the full spectrum of healthcare solutions today to deliver the breakthroughs of tomorrow and profoundly impact health for humanity. Learn more at https://www.jnj.com/. Fueled by innovation at the intersection of biology and technology, we’re developing the next generation of smarter, less invasive, more personalized treatments. Ready to join a team that’s pioneering the development and commercialization of Intravascular Lithotripsy (IVL) to treat complex calcified cardiovascular disease. Our Shockwave Medical portfolio aims to establish a new standard of care for medical device treatment of atherosclerotic cardiovascular disease through its differentiated and proprietary local delivery of sonic pressure waves for the treatment of calcified plaque. Position Overview We are looking for a high-performing individual to serve in a high-profile position driving global launches for a therapy that is changing the interventional landscape. Your primary focus will be increasing coronary IVL’s penetration in existing markets, launching in new international markets, and driving a blockbuster U.S. launch. This individual will play a key role in collaborating with the R&D, quality, regulatory, marketing, sales training, clinical, operations, manufacturing, and sales teams to ensure that the launches go smoothly and meet their objectives. This individual will also develop and execute marketing programs across the globe. The ideal candidate desires to be part of one of the most exciting startups in the cardiovascular space at the inflection point of commercialization. This is a visible role that will be vital to the company’s success. Responsibilities: - Develop and execute comprehensive US strategies for new/existing products including: - developing product positioning, and clinical and economic value proposition - defining marketing messages and collateral - developing sales and physician education programs - training both domestic and international sales teams - collaborating with key opinion leaders (KOLs) in developing the above - Developing product demand forecasts and track business performance against objectives and forecasts; formulating new approaches and strategies as needed - Champion product commercialization activities across multiple internal and external groups by collaborating with and influencing operations, regulatory, clinical, quality, sales, sales training, medical affairs, etc. - Lead market research to understand behaviors, test messaging and identify opportunities - Establish relationships with key opinion leaders in the field and working with them to develop content for our marketing channels - Acquire and analyze feedback from key opinion leaders, current and potential customers, third party market research and internal stakeholders - Possess an in-depth knowledge of the interventional cardiology community trends and more specifically, the segments targeted by assigned products, including the motivators for action An internal pre-identified candidate for consideration has been identified. However, all applications will be considered. Requirements: - Minimum 10 years of professional marketing/product management experience with at least 5 in cardiovascular MedTech is required - Bachelor’s degree required; MBA preferred - Experience bringing new novel products to market - Ability to develop relationships with key opinion leaders and to modify strategies and tactics when necessary based on voice of customer and emerging trends - Cross functional team leadership experience required. Ability to collaborate and work with others in a dynamic, matrix environment - Outstanding interpersonal skills including developing relationships in all levels of the organization and indirectly influencing business objectives - Ability to work in a fast-paced environment as individual contributor or as part of team, while managing multiple priorities and adapting to changing requirements - Sales force engagement experience preferred - There may be continuous sitting for prolonged periods (more than 2 consecutive hours in an 8-hour day) - Positioned will be based remote, with up to 30% travel may be required (Global & U.S.) - Employee may be required to lift objects up to 25lbs or more. Employees will be required to work in an air-conditioned office space and possibly perform some tasks in our non-temperature-controlled warehouse space. Johnson & Johnson is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, age, national origin, disability, protected veteran status or other characteristics protected by federal, state or local law. We actively seek qualified candidates who are protected veterans and individuals with disabilities as defined under VEVRAA and Section 503 of the Rehabilitation Act. Johnson & Johnson is committed to providing an interview process that is inclusive of our applicants’ needs. If you are an individual with a disability and would like to request an accommodation, please contact us via https://www.jnj.com/contact-us/careers or contact AskGS to be directed to your accommodation resource. Required Skills: Financial Project Management, Key Client Relationships, Launch Strategy, Relationship Building, Strategy Development Preferred Skills: Brand Marketing, Brand Positioning Strategy, Communication, Customer Centricity, Customer Intelligence, Data Analysis, Data-Driven Decision Making, Data Savvy, Execution Focus, Financial Analysis, Financial Management, Organizing, Presentation Development, Product Development Lifecycle, Product Improvements, Product Management, Product Portfolio Management, Product Strategies, Stakeholder Management, Strategic Thinking, Technical Credibility The anticipated base pay range for this position is : $142,000.00 - $244,950.00 Additional Description for Pay Transparency: Subject to the terms of their respective plans, employees are eligible to participate in the Company’s consolidated retirement plan (pension) and savings plan (401(k)). This position is eligible to participate in the Company’s long-term incentive program. Subject to the terms of their respective policies and date of hire, employees are eligible for the following time off benefits: Vacation –120 hours per calendar year Sick time - 40 hours per calendar year; for employees who reside in the State of Colorado –48 hours per calendar year; for employees who reside in the State of Washington –56 hours per calendar year Holiday pay, including Floating Holidays –13 days per calendar year Work, Personal and Family Time - up to 40 hours per calendar year Parental Leave – 480 hours within one year of the birth/adoption/foster care of a child Bereavement Leave – 240 hours for an immediate family member: 40 hours for an extended family member per calendar year Caregiver Leave – 80 hours in a 52-week rolling period10 days Volunteer Leave – 32 hours per calendar year Military Spouse Time-Off – 80 hours per calendar year
• Serve as the Physician Clinical Reviewer for Interventional Pain Management, reviewing cases that do not initially meet the applicable medical necessity guidelines • Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers • Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process • Provides clinical rationale for standard and expedited appeals • Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner • Participates in on-going training per inter-rater reliability process • May function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management
• Serve as the senior leader of the North America Medical Affairs field function, contributing to medical strategy development and translating strategy into clear, measurable field execution plans. • Lead and develop a multi‑level Field Medical team (Directors, Managers, and MSLs), driving performance, accountability, coaching, and career development. • Provide operational leadership for the MSL organization, including territory design, activity planning, and execution standards to ensure consistent, high‑quality field engagement. • Maintain budgetary and resource oversight for the field team, ensuring efficient allocation of headcount and resources aligned to strategic priorities. • Build and sustain strong cross‑functional partnerships to ensure field activities are aligned, collaborative, and well‑coordinated. • Ensure all field medical activities are conducted in a compliant, ethical, and scientifically rigorous manner in accordance with local regulations and company standards. • Serve as a key link between the field and internal stakeholders, synthesizing insights to inform medical strategy and evidence planning. • Foster a culture of scientific excellence, continuous improvement, and patient‑centricity across the Field Medical organization.


