Job Information
CVS Health Senior Medical Director Precertification Team in Work at Home, Connecticut
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:
Aetna, a CVS Health Company, has an outstanding opportunity for a Senior Medical Director to provide end-to-end clinical and operational leadership for Medicare and other activities, ensuring the highest standards of quality, compliance, and efficiency across the continuum of services. This leader is responsible for developing, training, and managing the Precertification Team, ensuring compliance, efficiency, and evidence-based decision making, driving process improvement, and fostering a collaborative team culture. This senior level MD serves as a key liaison between clinical and non-clinical stakeholders to ensure effective operations, communication, and strategic alignment.
This role provides strategic leadership and oversight for clinical operations by developing and implementing clinical policies and protocols, ensuring high-quality patient care, overseeing clinical functions, promoting evidence-based practices, and collaborating with cross-functional leaders to improve clinical outcomes and patient safety. They apply medical expertise, leadership skills, and knowledge of industry standards to drive clinical excellence, optimize resources, and contribute to the overall success of the organization's clinical operations.
Primary Job Duties & Responsibilities:
Provides strategic direction, professional oversight, and leadership throughout theprecert process and other clinical operations.
Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.
Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.
Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.
Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.
Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.
Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.
Leads teams through Medicare audits and on-going audit readiness.
Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.
Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.
Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.
Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.
Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.
Required Qualifications:
MD or DO with active, unrestricted license and board certification in an ABMS or AOA recognized specialty
Minimum 5 years of direct patient care in a clinical setting
Minimum 5 years in utilization management, precertification, or related roles
Deep expertise in Medicare regulations, including NCDs, LCDs, Medicare manuals, and regulatory references
Proven ability to interpret and apply Medicare guidelines to complex case review and decision-making
Advanced knowledge of medical coding standards, compliance requirements, and oversight of coding practices
Demonstrated leadership in managing teams, driving process improvement, and ensuring regulatory compliance
Successful track record guiding teams through Medicare audits and maintaining audit readiness
Strong interpersonal, communication, and cross-functional stakeholder management skills
Commitment to developing talent and fostering an inclusive, high-performing team culture
Preferred Qualifications:
Experience working in large, matrixed healthcare organizations
Familiarity with data analytics and performance management tools
Certified Professional Coder (CPC) credential or equivalent certification
Proficiency with multiple documentation platforms for acute utilization management and appeals
Prior leadership roles with increasing responsibility
Education:
MD or DO
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 (https://learn.bswift.com/cvshealth-mainland) .
We anticipate the application window for this opening will close on: 05/01/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
CVS Health is an equal opportunity/affirmative action employer, including Disability/Protected Veteran — committed to diversity in the workplace.