Senior Medical Director Medicaid

Responsibilities

• Leads, develops, directs and implements 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.
• Ensure compliance with clinical goals through monitoring care management performance.
• Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff.
• Responsible for recommending changes and enhancements to current managed care, review guidelines
• clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods
• Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
• Leads clinical staff in the coordination of quality care 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.
• Responsibility for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
• Expands Aetna's medical management programs to address member needs across the continuum of care.
• Required Qualifications / Licenses : Five (5) or more years of experience in clinical practice.
• Five (5) or more years administrative experience in the health care industry or managed care.
• M.D. or D.O., Active Board Certification in an ABMS or AOA recognized specialty, including post-graduate direct patient care experience.
• Current and Active State Medical License without encumbrances.
• Preferred Experience: Previous UM experience with a Health Plan or Health / Hospital System.
• Previous Medicaid experience strongly preferred.
• Previous experience managing a team.
• Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts.
• Key Deliverables and Expectations: Participates in Executive Director, Utilization Management led meetings as is appropriate.
• Excellent communication skills; liaise with all stakeholders: clinicians, and medical directors, and providers.
• Collaborative and strategic in identification of scorable action items (SAI) in Medicaid.
• Other assigned projects and tasks.
• Education M.D. or D.O., Active Board Certification in an ABMS or AOA recognized specialty, including post-graduate direct patient care experience.
• Pay Range The typical pay range for this role is: $184,112.00 - $396,550.00 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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments .
• We anticipate the application window for this opening will close on: 07/17/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.