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TX STAR+PLUS LTSS Medical Director

Primary Location: Dallas, TX
Additional Locations: TX-Austin, TX-Dallas, TX-Houston
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Description:
Position Summary:

The LTSS Medical Director (LTSS MD) directs health care services for individuals with physical, intellectual and/or developmental disabilities. The LTSS MD oversees and is responsible for all primary physical and behavioral health services provided to individuals receiving LTSS. This individual also oversees comparable populations and all clinical activities pertaining to the operation of LTSS programs and services. These include preventive care, management and coordination of chronic conditions and physical health needs, and integration and coordination of primary and other physical health services for members receiving LTSS.

The LTSS MD is responsible for working with the CMO, behavioral health medical director, pharmacy director and the Medical Management director to ensure the integration of physical and behavioral health services, in addition to supporting LTSS, as applicable, for individuals in each of these populations. This individual will also oversee quality improvement initiatives regarding behavioral supports and the appropriate use of psychotropic medications in each of these populations.

Primary Responsibilities:

Expands Aetna's medical management programs to address member needs across the continuum of care.

Supports the Medical Management staff, ensuring timely and consistent responses to members and providers.

Provides medical review and support for case management and care coordination staff to ensure optimal care is rendered to our members, according to the terms of the benefit the member receives.

Responsible for daily prior authorization reviews, concurrent reviews, and reviews of claim determinations, providing clinical, coding, and reimbursement expertise including denial decisions for cases that do not meet established criteria.

Acts as a business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams in conjunction with the chief medical officer.

Background / Experience:

2-3 years of experience in healthcare delivery systems (i.e., clinical practice and healthcare industry).

Active and current state medical license without encumbrances.

M.D. or D.O.; board certification in a recognized specialty, including post-graduate direct patient care experience (at least five years preferred).

Internal medicine and/or family practice preferred.

FUNCTIONAL EXPERIENCES:

Functional - Medical Management/Medical Management - Case Management/1-3 Years
Functional - Medical Management/Medical Management - Disease management/1-3 Years

TECHNOLOGY EXPERIENCES:

Technical - Desktop Tools/Microsoft Outlook/1-3 Years/End User
Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User

ADDITIONAL JOB INFORMATION:

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.






Additional Job Information:
  • Use of personal vehicle when traveling in the field, must have active and valid TX driver's license, reliable transportation and vehicle insurance.
  • DALLAS SERVICE AREA: Collin, Dallas, Ellis, Hurt, Kaufman, Navarro, and Rockwall counties.
  • HIDALGO SERVICE AREA: Cameron, Duval, Hidalgo, Jim Hogg, Maverick, McMullen, Start, Webb, Willacy and Zapata counties.
  • BEXAR SERVICE AREA: Atascosa, Bandera, Bexar, Comal, Guadalupe, Kendall, Medina, and Wilson counties
  • HARRIS SERVICE AREA: Austin, Brazoria, Fort Bend, Galveston, Harris, Matagorda, Montgomery, Waller and Wharton counties.


Required Skills:
Benefits Management - Interacting with Medical Professionals, Finance - Managing Aetnas Risk, General Business - Demonstrating Business and Industry Acumen

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, Benefits Management - Supporting Medical Practice, Leadership - Collaborating for Results

Functional Skills:
Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Direct patient care (hospital, private practice), Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Managed Care/Insurance Clinical Staff

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Potential Telework Position:
Yes

Percent of Travel Required:
10 - 25%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

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