Medical DirectorPrimary Location: Cary, North Carolina
Additional Locations: NC-Cary Apply
Operating with a balance of internal and external-facing activities that support a shift to a higher-touch, patient-centric focus, the Medical Director will develop, implement, support, and promote population health strategies, tactics, policies, and programs that drive the delivery of high value healthcare to establish a sustainable competitive business advantage for Aetna. These strategies, policies, and programs are comprised of care management, utilization management, quality improvement, network management as well as clinical coverage protocol. The Medical Director will be provider facing and have fluency in data analytics.
This position is focused on utilization management (admission and concurrent reviews for both commercial and managed Medicare inpatient and post acute confinements, precertification requests, peer to peer review and appeals) to render timely coverage determinations in accordance with member benefits, NCQA standards and Aetna or CMS policies and guidelines.
Ability to collaborate with all stakeholders, understanding the guidelines/basics (how to access) the requirements, opportunities to shape within the scope in the role as a Health plan medical director.
Analytics-Oriented Care: Ability to analyze data (e.g., medical cost trends) and articulate trend and solutions. Ability to manage complex cases and client relationships with plan sponsors. Proactive Virtual and Physician Engagement: Leveraging multi-channel platforms and digital technology to interface with internal and external customers in virtual and physical settings.
End to End Market Understanding: Strong business acumen. Understands and proficient articulating products, financial impacts and market demands. Consultant and supplier of actionable information. Expertise in market/state DOL regulations delivering HEDIS/STARS consultation.
Communications: Both oral and written skills and comfort in presenting to varied groups. Building and fostering relationships and partnering with the external community and providers in a pro-active approach to population health.
Using data analytics to inform and influence population health to drive behavior change and expand Aetna's medical management programs to address specific member conditions across the continuum of care.
Collaborating with the Medical Management staff both internally and externally ensuring timely and consistent responses to members and providers. Providing clinical expertise and business direction in support of medical management programs through active collaboration and participation in clinical team activities.
Acting as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Attend & engage in Sales presentation meetings if needed from time to time providing the value prop/story behind the partnerships.
Executing predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
Manage UM transactional work (front line reviews and appeals).
Building and inspiring a culture of continuous improvement for better quality of care.
Overseeing utilization review/quality assurance directing case management.
Provide UM services based on business demands and shifting business needs.
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
The highest level of education desired for candidates in this position is a MD or DO
LICENSES AND CERTIFICATIONS
Medical/Medical License - North Carolina is desired
Active unrestricted state medical license required
Board Certification in Aetna recognized specialty required
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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'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.
60611Required Skills: General Business - Consulting for Solutions, Leadership - Collaborating for Results, Leadership - Driving a Culture of Compliance Desired Skills: Benefits Management - Maximizing Healthcare Quality, General Business - Communicating for Impact, General Business - Turning Data into Information Functional Skills: Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - General Management Technology Experience: Desktop Tool - Microsoft Exchange, Desktop Tool - Microsoft Explorer, Desktop Tool - Microsoft PowerPoint, Desktop Tool - TE Microsoft Excel Education: Medical - Medical License (for all states) Potential Telework Position: Yes Percent of Travel Required: 0 - 10% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Click here to review the benefits associated with this 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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