Medical Director, Behavioral Health - SIU

Before you apply

Job source

Workday

Applying on

cvshealth.wd1.myworkdayjobs.com

Workplace

Fully remote

US state

CT

Category

Healthcare

Link last checked

1 hour ago

Posted

1 day ago

Closes

No stated closing date

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About the role

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. Behavioral Health SIU Medical Director — Turn Clinical Insight into National Impact Position Summary: Bring your psychiatric expertise to a role where clinical judgment can improve care at scale. As health care costs rise and access to consistent, high-quality care remains challenging, care with limited clinical benefit and fraud, waste, and abuse divert resources from members who need them. At Aetna, a CVS Health Company, you will proactively surface new investigative opportunities and support existing investigations to advance quality, safety, and responsible stewardship across one of the nation’s largest health care organizations. Join a high-impact Behavioral Health Special Investigations Unit that protects members from potential harm, reduces unwarranted variation in care, and safeguards health care resources. Over the past three years, investigative efforts—including collaboration with the FBI—have identified more than $300 million in fraudulent claims. In this role, you will combine psychiatric expertise, population-level data, and advanced analytics to uncover meaningful patterns and help turn insight into action. This full-time, remote position may be based anywhere in the United States. Why this role: You will influence decisions at scale, collaborate with clinical, investigative, legal, compliance, and data experts, and help shape how advanced analytics and AI support safer, higher-value behavioral health care. As the Behavioral Health SIU Medical Director, you will apply psychiatric expertise to reviews of medical records, CPT codes, and HCPCS codes involving suspected fraud, waste, abuse, care of limited clinical benefit, or potentially harmful practice variation. You will translate complex clinical evidence and data into clear findings, strategic recommendations, and practical interventions that protect members and resources. In this role, a successful candidate will: - Serve as the psychiatric advisor to SIU investigators and leaders, reviewing medical records, coding, and claims involving suspected fraud, waste, abuse, or harmful practice variation. - Proactively surface new investigative opportunities while providing clinical support for active investigations and related legal actions. - Use clinical expertise, population-level data, advanced analytics, AI, and practice-pattern insights to identify trends, prioritize investigations, and scale clinical impact. - Lead cross-functional investigations with clinical, claims, legal, compliance, network, quality, data, and operational partners to address root causes and implement sustainable solutions. - Assess member risk and care variation, document clear findings, and translate complex evidence into recommendations for leaders, customers, and other stakeholders. - Prepare well-supported cases for clinical and legal review and, when required and approved by Legal, provide testimony in civil or criminal proceedings. - Conduct required peer-to-peer reviews and model Aetna’s Employee Competencies in all interactions. Required Qualifications: - Five or more years of experience in a health care delivery setting, including clinical practice. - Board certification in psychiatry; board eligibility alone is not sufficient. Additional board certification in child , addiction or forensic psychiatry helpful but not required - Knowledge of policies and procedures governing payment of health care claims. Preferred Qualifications : We are especially interested in candidates who bring one or more of the following: - At least two years of health c

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