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Position Summary
Aetna, a CVS Health Company, a Fortune 4 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). Candidate must reside in Ohio or any surrounding state such as Pennsylvania, Kentucky, Indiana, West Virginia or Michigan.**

As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among CMEs (Care Management Entities), MCOs, vendors, providers, PCSAs (Public Children Services Agencies) and Ohio Department of Medicaid to support specialization in addressing critical needs.

The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

The Medical Director provides oversight for medical policy implementation, and participates in the development, implementation, and evaluation of clinical/medical programs.

This is a full-time telework position, with travel up to 15% required for state meetings and visits to the New Albany office as needed.

• 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.
• Oversees 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 and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
• Expectation of collaboration with CMO. This includes supporting the execution of the CMOs clinical goals and being a subject matter expert resource to all OhioRISE departments (clinical and operational), CMEs, Providers, and state stakeholders. MDR will assist OhioRISE in achieving clinical contract deliverables and Aetna/CVS Health enterprise endeavors.

Required Qualifications
• Active Ohio medical license without encumbrances. Persons willing to obtain will be considered.
• Residence in Ohio or one of the surrounding states Pennsylvania, Kentucky, West Virginia, Indiana or Michigan.
• 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

Preferred Qualifications
• Clinical experience with pediatric populations.
• Experience with multisystem involved youth.
• Experience with SUD (Substance Use Disorder) treatment.
• Experience with ASAM (American Society of Addiction Medicine) Criteria.

Education

• M.D. or D.O., Board Certification required in a recognized specialty.
• Post-graduate direct patient care experience.
• Board Certification in Child & Adolescent Psychiatry preferred. Physicians board-certified in Pediatrics or Adolescent Medicine with significant behavioral health or Addiction Medicine experience/specialization will be considered.

Pay Range

The typical pay range for this role is:

$174,070.00 - $374,900.00

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. 
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.  As for time off, Company employees enjoy Paid Time Off (“PTO”) or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies. 
 
For more detailed information on available benefits, please visit jobs.CVSHealth.com/benefits

We anticipate the application window for this opening will close on: 08/30/2024