CVS Health
Medical Director (Medical Policy Ops-DRG)
$174K–$375K
CT - Work from home · Remote · Director · Full-time · Posted Aug 21, 2026
- Experience
- Five (5) or more years in a health care delivery system and health care industry.
- Education
- M.D. or D.O.
About the job
Provides clinical expertise and conducts medical, claims, appeals, benefit, and DRG reviews to support clinical and payment policy and high-quality care.
What you'll do
- Review appeals, claims, and predeterminations of covered benefits in Commercial and Medicare environments; perform DRG reviews and ICD-10 code selection.
- Apply clinical coding and reimbursement expertise to ensure correct application of policies and practices to service and payment requests.
- Contribute clinical and payment policy expertise, use data analysis to identify quality improvement opportunities, and collaborate with work groups and teams.
What they ask for
- Five or more years of experience in a health care delivery system and health care industry.
- Active, current state medical license without encumbrances.
- M.D. or D.O., ABMS-recognized board certification, and postgraduate direct patient care experience.
Nice to have
- Health plan/payor experience; experience with DRG reviews.
- Foundational skills in medicine, health policy, HCPCS/CPT coding, clinical policy, reimbursement, and health care systems; strong written and verbal communication.
Pay
$174,070.00 - $374,920.00 USD base salary
Tools
HCPCS, CPT, ICD-10, DRG
Model-written summary · the original posting is authoritative