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Medical Director (Kentucky & Ohio Markets)

Primary Location: Lexington, Kentucky
Additional Locations: KY-Lexington, KY-Louisville, OH-Cincinnati, OH-Columbus, OH-New Albany, OH-Toledo
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Description:

POSITION SUMMARY
The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsor, and regulatory agencies and participates in the strategic medical management for our plan sponsors. The Medical Director will partner with medical management to increase effectiveness of medical management programs and promote integration of other Aetna medical programs

The Medical Director is part of a team of Medical Directors supporting our Ohio and Kentucky markets with continued growth expected in 2019.

Fundamental Components:

Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.

Manage UM transactional work (front line reviews and appeals).

Build and inspire a culture of continuous improvement for better quality of care.

Oversee utilization review/quality assurance directing case management.

Provide UM services based on business demands and shifting business needs

Lead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits.

Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (eg. telephonic rounds)
in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management.

Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.

Proactively use data analysis to identify opportunities for overall value improvement (including both financial as well as quality improvement)
, to positively influence the effective delivery of quality care.

Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.

Work collaboratively with other functional areas that interface with medical management within the National Account Care Management Solutions Team including provider relations, sales, benefits, healthcare delivery, national medical services and national accounts to achieve the business goals of the company.

Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.

Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved.

EDUCATION
The highest level of education desired for candidates in this position is a MD or DO

LICENSES AND CERTIFICATIONS
Medical/Medical License (MD) or (D0) is required
Medical/Board Certified, National Board Of Medical Examiners is required
Primary Care and related specialties as well as Physical Medicine and Rehabilitation preferred

Medical/DEA License is required
An Active Unrestricted State Medical License is required. Will Require Ohio and KY medical license or ability to obtain them in due time.
Active Board Certification in a recognized specialty is required

FUNCTIONAL EXPERIENCES

Functional - Medical Management/Medical Management - Direct patient care/4-6 Years
Functional - Medical Management/Medical Management - Administration/Management/1-3 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 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

REQUIRED SKILLS
Benefits Management/Interacting with Medical Professionals
Leadership/Driving a Culture of Compliance


DESIRED SKILLS
Benefits Management/Supporting Medical Practice
Leadership/Collaborating for Results

TELEWORK SPECIFICATIONS
Work at Home with Kentucky, SW or Western Ohio
preferred though open to other Ohio locations

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.

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.



Potential Telework Position:
Yes

Percent of Travel Required:
0 - 10%

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

Click To Review Our Benefits (PDF)

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