Medical Director - Behavioral Health (Special Investigations)

About the job

Bring your heart to CVS Health.

 

Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

 

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

 

Position Summary

 

Aetna, a CVS Health 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 from home) full-time position and can be based anywhere in the United States.

 

• The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse.
• Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
• Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse.
• Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions.
• Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.
• Maintains open communication with constituents within the company.
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Documents all appropriate information related to medical record review determinations.
• Represents Aetna as a witness in court actions, as required, and as approved by Legal. The expectation is that the BH Medical Director will have a high level of knowledge when providing testimony during civil and criminal proceedings. The BH Medical Director must be able to travel, as needed, and provide detailed testimony based upon the BH Medical Director’s documentation.
• Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review - Exhibits behaviors outlined in Employee Competencies.

 

Required Qualifications

 

• Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice)
• Board Certified Psychiatrist not "Board Eligible" - Active and Unencumbered license to practice medicine
• Knowledge of pertinent policies and procedures related to claims payment of healthcare related services.

 

Preferred Qualifications

 

• 2 years’ experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles
• Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
• Psychiatric experience in providing clinical guidance and input in the business analytic building process.
• Child and Adolescent Psychiatrist

 

Education

 

Active and current state medical license(s) without encumbrances - M.D. or D.O., Board Certification in psychiatry, including 5 years of post-graduate direct patient care experience.

 

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.