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Position Summary:

Aetna Duals Center of Excellence is seeking a dedicated and experienced Behavioral Health Medical Director. The ideal candidate will be a board-certified psychiatrist with a current, unencumbered state license, and at least four (4) years of training in a medical specialty. The Behavioral Health Medical Director will ensure timely medical decisions, including after-hours consultation, and will share responsibility for managing the behavioral health services delivery system.

This is a Work from Home Remote Position with travel as needed but most likely less than 10% Travel.

Preferences for NY, NJ, VA, OH, MI and IL licenses. Able to get additional licenses in key states, where required.

Responsibilities:

• Directs the utilization review process and oversee the quality of utilization determinations.

• Responsible for overall medical policies to ensure the appropriate and most cost-effective medical care is received, and for the day-to-day management of Behavioral Health Medical Director Staff.

• Responsible for recommending changes and enhancements to current member management, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.

• Ensuring consistency in the application of utilization management standards, including those implemented by subcontracted entities for BH services.

• Review and resolution of quality-of-care concerns.

• Participation in clinical staff recruitment and ongoing performance improvement.

• Responsible for predetermination reviews and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.

• Support submission and completion of Potential Quality of Care Determinations (PQOC) and complete reviews as needed.

• Participate in BH transition of care (TOC) rounds and care management activities as needed.

• Will serve as a collaborator with Duals Center of Excellence in designated markets to ensure compliance with UM and quality programs and support initiatives, programs, and solutions.

• Support duties as required regarding utilization management of the service benefit and pharmacy benefit within the state health plan and additional duties as assigned.

• Actively participate in continuous improvement activities, other activities that support quality of care and total cost of care oversight.

Required Qualifications / Licenses:

• Three (3) or more years of experience in post-residency training clinical practice.

• Three (3) or more years administrative experience in the health care industry or managed care.

• Independently motivated and capable of researching and adjudicating Medicare and Medicaid benefit and coverage decisions.

• Strong communication skills both written and verbal.

• Board Certification in ABMS recognized specialty of Adult Psychiatry

• Current and Active State Medical License without encumbrances.

• Able to get additional licenses in key states, where required.

• Ability to attend in-person meetings and manage after-hours/ on-call consultations when needed.

Preferred Experience:

• Previous UM experience with a Health Plan or Health / Hospital System.

• Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts.

• Previous Medicare and Medicaid experience.

• Experience in managing behavioral health services.

Education

• M.D. or D.O.

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: 04/30/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.