[Hiring] Medical Director, Behavioral Health @CVS Health

Role Description

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. This is a remote based (work from home) full-time position and can be based anywhere in the United States.

The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse.

• Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
• Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse.
• Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions.
• Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.
• Maintains open communication with constituents within the company.
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate information related to medical record review determinations.
• Represents Aetna as a witness in court actions, as required, and as approved by Legal.
• The expectation is that the BH Medical Director will have a high level of knowledge when providing testimony during civil and criminal proceedings.
• The BH Medical Director must be able to travel, as needed, and provide detailed testimony based upon the BH Medical Director’s documentation.
• Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review.
• Exhibits behaviors outlined in Employee Competencies.

Qualifications

• Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice).
• Board Certified Psychiatrist not "Board Eligible" - Active and Unencumbered license to practice medicine.
• Knowledge of pertinent policies and procedures related to claims payment of healthcare related services.

Requirements

• 2 years’ experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles.
• Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
• Psychiatric experience in providing clinical guidance and input in the business analytic building process.
• Child and Adolescent Psychiatrist.

Education

• Active and current state medical license(s) without encumbrances - M.D. or D.O., Board Certification in psychiatry, including 5 years of 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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.