medical management director

CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;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 &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Position Summary</b><br>
Aetna, a CVS Health Company, a Fortune 6 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.<br>
<br>
**This is a remote based (work at home) based anywhere in the US.**<br>
<br>
Aetna, a CVS Health Company, has an exciting opportunity for a Medical Director (Spine) that can be remote based, work from home.
</p><p></p><p>The Medical Director (Spine) will be a Subject Matter Expert (SME) with a background in Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically.
</p><p></p><p>Expands Aetna's medical management programs to address member needs across the continuum of care.
</p><p></p><p>Supports the Medical Management staff ensuring timely and consistent responses to members and providers.
</p><p></p><p>Leads all aspects of 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.
</p><p></p><p>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.</p><p></p><div>
Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise, using multiple computer based applications.<br>
<br>
<b>Required Qualifications</b><br>
<ul><li>2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.</li></ul></div><div><ul><li><br>
Active and current state medical license without encumbrances.</li></ul></div><div><ul><li><br>
M.D. or D.O.,Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically.</li></ul><br>
<b>
Preferred Qualifications</b><br>
<ul><li>Previous healthcare insurance experience.</li></ul><br>
<b>
Education</b><br>
<ul><li>2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.</li></ul></div><div><ul><li><br>
Active and current state medical license without encumbrances.</li></ul></div><div><ul><li><br>
M.D. or D.O.,Board Certification in a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically. Neurosurgery, including post-graduate direct patient care experience specifically.</li></ul></div><p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$174,070.00 - $374,920.00<p><br>
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&rsquo;s equity award program.</p><p><br>
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.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in our comprehensive and competitive mix of pay and benefits &ndash; 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:</p><ul><li><p><b>
Affordable medical plan options,</b> a <b>401(k) plan </b>(including matching company contributions), and an <b>employee stock purchase plan</b>.</p></li><li><p><b>
No-cost programs for all colleagues </b>including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</p></li><li><p><b>
Benefit solutions that address the different needs and preferences of our colleagues</b> 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.</p></li></ul><p></p><p>
For more information, visit https://jobs.cvshealth.com/us/en/benefits</p><p></p>
We anticipate the application window for this opening will close on<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Medical Director - Spine

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;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 &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><h2 class="jobSectionHeader"><b>
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.</b><br>
<br>
<b>In this role you will:</b></h2><ul><li><h2 class="jobSectionHeader"><b>
Provide oversight for medical policy implementation.</b></h2></li><li><h2 class="jobSectionHeader"><b>
Participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.</b></h2></li><li><h2 class="jobSectionHeader"><b>
Support the Medical Management staff ensuring timely and consistent responses to members and providers.</b></h2></li></ul><h2 class="jobSectionHeader"><b>
</b></h2><h2 class="jobSectionHeader"><b>
As a Medical Director you will:
</b></h2><ul><li><h2 class="jobSectionHeader"><b>Focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews and reviews of claim determinations.</b></h2></li><li><h2 class="jobSectionHeader"><b>
This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.</b></h2></li><li><h2 class="jobSectionHeader"><b>
The Medical Director will provide clinical, coding, and reimbursement expertise as well as directing case management when necessary.</b></h2></li><li><h2 class="jobSectionHeader"><b>
In this role you will provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.</b></h2></li><li><h2 class="jobSectionHeader"><b>
The Medical Director will act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.</b></h2></li></ul><h2 class="jobSectionHeader"><b><br>
</b></h2><h2 class="jobSectionHeader"><br>
<br>
<b>Required Qualifications:</b></h2><ul><li><b>2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.</b></li><li><b>Active and current medical license without encumbrances</b></li><li><b>M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.</b></li></ul><h2 class="jobSectionHeader"><br>
<b>
Preferred Qualifications:</b></h2><ul><li><b>Five or more years of direct patient care experience</b></li><li><b>Preferred licensed in TX, CA, or FL</b></li><li><b>Previous UM experience with a Health plan/payor experience.</b></li><li><b>Electronic medical systems/record experience</b></li><li><b>Managed Care experience</b></li><li><b>Board certification in Internal Medicine, Family Medicine, Emergency Medicine, or Med/PM&amp;R</b></li></ul><h2 class="jobSectionHeader"><br>
<b>
Education</b></h2><ul><li><b>Active and current state medical license without encumbrances</b></li><li><b>M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience</b></li></ul><p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$174,070.00 - $374,920.00<p><br>
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&rsquo;s equity award program.</p><p><br>
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.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in our comprehensive and competitive mix of pay and benefits &ndash; 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:</p><ul><li><p><b>
Affordable medical plan options,</b> a <b>401(k) plan </b>(including matching company contributions), and an <b>employee stock purchase plan</b>.</p></li><li><p><b>
No-cost programs for all colleagues </b>including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</p></li><li><p><b>
Benefit solutions that address the different needs and preferences of our colleagues</b> 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.</p></li></ul><p></p><p>
For more information, visit https://jobs.cvshealth.com/us/en/benefits</p><p></p>
We anticipate the application window for this opening will close on: 04/30/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Medical Director - Commercial

Blue Cross Blue Shield of Arizona

<div><div>Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.</div><div></div><div>
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:</div><ul><li><div>
Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week</div></li><li><div>
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week</div></li><li><div>
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month</div></li><li><div>
Onsite: daily onsite requirement based on the essential functions of the job</div></li><li><div>
Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building</div></li></ul><div></div><div>
Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.</div><div></div><div>
This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.</div><div></div><div><div>
PURPOSE OF THE JOB</div><ul><li>
Direct, lead and provide professional oversight for medical management activities related to utilization management, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community.</li></ul><div></div><div>
QUALIFICATIONS</div><div></div><div>
REQUIRED QUALIFICATIONS</div>
Required Work Experience<ul><li>
3 years of experience in a clinical setting</li><li>
1 year of experience in physician leadership role, including quality review, utilization review and other managed care functions</li></ul>
Required Education<ul><li>
Medical Degree</li></ul>
Required Licenses<ul><li>
Active, current, and unrestricted license to practice medicine in the State of Arizona (a state in the United States).</li></ul>
Required Certifications<ul><li>
Board Certification</li></ul><div></div><div>
PREFERRED QUALIFICATIONS</div>
Preferred Work Experience<ul><li>
3 years of experience in a primary care field</li></ul>
Preferred Education<ul><li>
N/A</li></ul>
Preferred Licenses<ul><li>
N/A</li></ul>
Preferred Certifications<ul><li>
N/A</li></ul><br>
<div></div>
<div>
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES</div></div><div></div><div><ul><li>
Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review.</li><li>
Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions.</li><li>
Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions.</li><li>
Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense.</li><li>
Review, and implement medical policies and other medical decision-making policies or procedures</li><li>
Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals.</li><li>
Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee.</li><li>
Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers</li><li>
Conduct, as appropriate, Appeal Peer Review cases in accordance with the required qualifications.</li><li>
Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.</li><li>
Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care.</li><li>
Provide leadership to staff and other professionals through clinical excellence, professional behavior and innovative thinking.</li><li>
Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.</li></ul></div><div><ul><li>
Identify opportunities to achieve administrative efficiencies while maintaining service.</li><li>
Maintain effective working relationships to ensure teamwork in achieving corporate goals.</li><li>
Contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.</li><li>
Coordinate activities between multiple divisions to achieve desired results.</li><li>
The position has an onsite expectation of 1 day per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.</li><li>
Perform all other duties as assigned.</li></ul></div><div></div><div>
COMPETENCIES</div><div></div><div>
REQUIRED COMPETENCIES</div><div>
Required Job Skills</div><ul><li>
 Strong written and verbal communications.</li><li>
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.</li><li>
Intermediate skill in word processing, spreadsheet and database software.</li><li>
Intermediate PC proficiency.</li></ul><div>
Required Professional Competencies</div><ul><li>
Interpersonal skills that allow for harmonious relationships with providers, members and coworkers</li></ul><div>
Required Leadership Experience and Competencies</div><ul><li>
N/A</li></ul><div></div><div>
PREFERRED COMPETENCIES</div><div>
Preferred Job Skills</div><ul><li>
N/A</li></ul><div>
Preferred Professional Competencies</div><ul><li>
N/A</li></ul><div>
Preferred Leadership Experience and Competencies</div><ul><li>
N/A</li></ul><div></div><div>
Our Commitment</div><div></div><div>
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.</div><div></div><div>
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.</div></div>

Medical Director - Hybrid

Prairie Ridge Health

<div><p>Prairie Ridge Health is looking for a team member to join our Clinic team in the role of Director of Clinic Operations. This position is a 1.0 FTE (40 hours per week) and as a key member of the leadership team, this position will work onsite and participate in an on-call rotation. The Director of Clinic Operations monitors and directs the daily operations of the Prairie Ridge Health (PRH) owned clinics consistent with the Mission, Vision and Values of PRH...</p>
<p><b>
POSITION SUMMARY</b></p>
<p>
The Director of Clinic Operations monitors and directs the daily operations of the Prairie Ridge Health (PRH) owned clinics consistent with the Mission, Vision and Values of PRH. The Director has responsibility for the hiring of employees for their areas, performance evaluations, and dismissal when appropriate. The Director is also responsible for communicating defined expectations to the staff and providing or developing the support, skill set, and competencies needed for the roles in each of the departments. The Director has oversight of staff development and identifying the strengths of the staff, budget development, and compliance with the Joint Commission, HIPAA, and other regulatory agencies. The Director possesses an in-depth professional working knowledge and the skills required to properly perform clinic operations services. The Director will coach, mentor, and recognize staff. They are responsible for ensuring the department is staffed in accordance with established guidelines, with quality, patient safety, and fiduciary expectations in mind. This position is responsible service line development, provider onboarding, for assuring excellent patient care, customer service and clinical outcomes. The Director works with staff to plan, develop and implement changes to existing operations and healthcare processes to meet current and future clinic service&rsquo;s needs. This position is accountable for managing, coordinating and planning patient care and services assuring that a high quality of patient care and satisfaction standards are achieved. In addition, the Director will work closely with PRH Financial Services, Medical Imaging, Laboratory, Surgical Services and Rehabilitation to ensure seamless service delivery. Decision making in order to manage daily functions and work toward continuous improvement in a team environment is a crucial element of this position.</p>
<p><b>
EDUCATION REQUIREMENTS/LICENSURE/CERTIFICATION/REGISTRATION:</b></p>
<ul>
<li>Bachelor&rsquo;s degree with 3 or more years of management experience; <b>OR</b> a high school graduate with 2 years of additional schooling and/or training and a minimum of 5 years of management experience required.</li>
<li>A degree in Healthcare Administration or equivalent experience in medical office management preferred.</li>
<li>Knowledge of compliance programs and laws and regulations.</li>
<li>Must display significant skills in communicating with and relating to physicians, including the ability to establish a productive and cohesive partnership with physicians; work closely with physicians and advanced practitioners to provide a positive and productive practice environment and patient friendly experience.</li>
<li>Knowledge and ability to use computer applications in health information and general applications such as Microsoft Office (Word, Excel, Outlook and PowerPoint) as well as electronic health records such as Epic.</li>
<li>Ability to communicate effectively verbally, in writing and in groups in order to establish sound working relationships with multiple departments and staff.</li>
<li>Previous experience in managing a minimum of 10 staff members.</li>
<li>Strong organizational, communication and interpersonal skills.</li>
<li>Proven critical thinking and problem-solving abilities, including resolving complex problems requiring innovative solutions.</li>
<li>Strong analytical skills.</li>
<li>Ability to present oneself and one&rsquo;s ideas with professionalism, clarity, confidence and poise.</li>
<li>Experience with a medical office practice and associated data collection analysis.</li>
<li>Previous experience with medical informatics.</li>
<li>Experience with process improvement.</li>
</ul>
<p><b>FTE: </b>1.0 (40 hours per week)</p>
<p><b>
Shift:</b> Monday-Friday, days. As a key member of the leadership team, this position will work onsite and participate in an on-call rotation.</p></div>

Director of Clinic Operations - 1.0 FTE

Life Works

<div><div><p><b>ON CALL REGISTERED NURSE</b></p><p>
Department: Residential Services</p><p>
FLSA Status: Non-Exempt</p><p>
Position Status: On-Call</p><p>
Position Location: Remote (Washington-based)</p><p>
Salary Grade: Residential Pay Grade 31</p><p>
Reports to: Director of Medical Supports</p><p>
Prepared/Revised Date: 1/29/2026</p><p><b>
ABOUT THE POSITION</b></p><p>
The On‑Call Registered Nurse provides clinical consultation and support to Life Works staff regarding medical or medication concerns for residential clients. This position ensures timely, accurate implementation of physician orders, updates Medication Administration Records (MARs), and guides staff in following appropriate medical protocols within RN scope of practice.</p><p><b>
Essential Duties and Responsibilities</b>:</p><div><b><i>
On‑Call Clinical Support</i></b></div><ul><li>
Respond to medical or medication‑related questions from staff during assigned on‑call periods.</li><li>
Provideclinical guidance that aligns with RN scope, physician orders, and Life Works policies.</li><li>
Redirect staff to the Delegating Nurse, Advice RN, on‑call provider, orprescribedphysician when clarification isrequired.</li></ul><div>
M<b><i>edication &amp; Documentation Management</i></b></div><ul><li>
Enter new prescriptions anddiscontinuemedications inTherapMARs based on provider orders.</li><li>
MaintainaccurateandtimelyMAR updates for clients supported during on‑call coverage.</li><li>
Document change‑of‑care notes with clear instructions for staff.</li></ul></div><div><div><b><i>
Collaboration &amp; Communication</i></b></div><ul><li>
Communicate promptly with the Director of Medical Supportsregardingsignificant medical issues or patterns of concern.</li><li>
Report urgent or unusual findings requiring follow‑up.</li><li>
Coordinate with providers and pharmacies when needed.</li></ul><div><b><i>
Training &amp; Equipment Support (As Needed)</i></b></div><ul><li>
Provide limited, as‑needed training to staff on equipment within RN competencies (wheelchairs, gait belts,hoyerlifts, catheters).</li><li>
Identifywhen staff requireadditionalcoaching and notify the Director of Medical Supports for scheduling.</li></ul><p></p><div><b><i><br>
Administrative Responsibilities</i></b></div><ul><li>
Provide weekly on‑call availability schedule to the Director of Medical Supports.</li><li>
Notify the Director of Medical Supportsimmediatelyof schedule changes.</li><li>
Create Medi‑set labels for clients receiving Medication Assistance as needed.</li></ul><p><b>
POSITION REQUIREMENTS</b></p><p><b>
EDUCATION:</b></p><p>
Graduate of an accredited nursing program (ADN or BSN).</p><p><b>
RELATED EXPERIENCE:</b></p><ul><li>
One to three years of experience as a practicing RN in a clinical, acute, or community setting.</li><li>
Experience working with individuals with developmental disabilities preferred.</li></ul><p><b>
CERTIFICATES, LICENSES, OR REGISTRATIONS:</b></p></div><div><ul><li>
Active RN license in Washington State.</li><li>
Successful completion of all required background checks (Washington State, FBI, DCYF).</li><li>
Pre‑employment drug screen.</li></ul><p><b>
REQUIRED COMPETENCIES:</b></p><div><b><i>
Professional Competencies</i></b></div><ul><li>
Strong clinical judgment and problem‑solving.</li><li>
Clear,concise,written,and verbal communication.</li><li>
Ability to remain calm and effective during on-call situations.</li><li>
Strong organizational and time‑management skills.</li></ul><div><b><i>
Technical Competencies</i></b></div><ul><li>
Proficiencyin Microsoft Office (Word, Excel, Outlook, PowerPoint).</li><li>
Ability to effectively useTherapor other cloud‑based client database systems.</li><li>
Accurate MARentryand documentation.</li></ul><div><b><i>
Working Conditions &amp; Physical Requirements</i></b></div><ul><li>
Remoteworkenvironment requiring reliable phone and internet access.</li><li>
Prolonged periods of computer use.</li><li>
Occasional travel to residential sites for training or follow‑up.</li><li>
Ability toliftupto 25 pounds for equipment demonstrations, when applicable.</li></ul><div><b><i>
Employment Requirements</i></b></div><ul><li>
MaintainRN licensure andrequiredcontinuing education.</li></ul></div><div><ul><li>
Comply withall Life Works policies, procedures, and documentation standards.</li><li>
Maintain confidentiality and adhere to HIPAA.</li></ul></div></div>

On-Call/ Relief RN

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Medical Director - Spine

Medical Director - Commercial

Medical Director - Commercial

Medical Director - Commercial

Medical Director - Hybrid

Director of Clinic Operations - 1.0 FTE

On-Call/ Relief RN