Medical Director Aetna Duals Center of Excellence

• 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: The Aetna Duals Center of Excellence (COE) operates Duals Integrated Plans and Medicare ISNP Plans in Ohio, Illinois, Michigan, Virginia, Pennsylvania
• New Jersey offering a variety of physical and behavioral health programs and services to its membership. Aetna is looking for a Medical Director to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review
• appeal request. The Medical Director is a work-at-home position located anywhere in the US. The Medical Director will work a full-time schedule Monday to Friday. The Medical Director can work from any state but will be required to work Eastern Standard Time or Central Standard time 8:00 AM - 5:00 PM. The Medical Director will also be expected to work 1 holiday and 8 weekend days (approximately 1 weekend per quarter) each year. Fundamental Components:
• Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials.
• Appeals – The medical director will perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs.
• Pharmacy coverage – The medical director will perform pharmacy reviews.
• The medical director will participate in and be able to lead rounds. Required Qualifications: Minimum 3-5 years of clinical practice experience. Two (2) + years of experience in managed care (Medicare and/or Medicaid) Experience with managed care (Medicare and Medicaid) utilization review preferred MD or DO
• Board certification in an ABMS or AOA recognized specialty is required. Active and current state medical license without encumbrances is required. Multiple state licensure a plus

Preferred Qualifications

• Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System.
• Licensed in or willing to obtain license in at least one state where we have an Integrated plan.
• Education MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine) 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 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.