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Executive Director, Medicaid Clinical Health Services

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
Position Summary:

The Executive Director
facilitates the delivery of appropriate, cost-effective, and quality medical benefits for the Medicaid beneficiaries. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure appropriate utilization. Services and strategies are comprised of network management support, clinical coverage policies and programs, and medical payment policies.

Provides clinical leadership for the Aetna Medicaid segment Utilization Management division which includes direct leadership for utilization management activities and strategic leadership across clinical services.

Fundamental Components:
  • Define, develop, guide and implement all assigned clinical functions for the Medicaid Modernization program.
  • Lead and drive clinical strategy and performance for Medicaid populations
  • Drive the strategic agenda for clinical management supporting multiple markets for the Medicaid products.
  • Partner with local market lead and MD management to analyze and support the utilization performance of all relevant markets.
  • Provide strategic guidance to other market clinical teams in matrixed support functions, i.e. QM, CM
  • Create strategic and tactical approaches to medical management that support relevant and value-based network strategies within the geographic markets.
  • Meet all market utilization goals in both quality of care and cost of care
  • Support and provide leadership accountability for NCQA accreditation and STARS results across the plans in a matrix environment
  • Oversee and ensure compliance with all applicable Federal and State regulations relevant to the plans function.
  • Lead a virtually integrated staff (including clinical and non-clinical members) within multiple geographic markets.
  • Provide subject matter expertise to pursue market growth opportunities and support implementations

Background Experience:
  • 8-12 years of Managed experience, Medicaid highly preferred
  • 6-9 years Planning, leading and organizing the resources of a team
  • 6-9 years Ability to engage at all levels, including physicians, vendors, administrative leaders, clinical leaders and staff.
  • 6-9 years Leading UM Committees/and or Clinical Review teams. Comprehensive experience using standardized clinical criteria (Milliman and/or InterQual for denials and authorization decisions, with attending escalation processes
  • 6-9 years Analyzing, interpreting and presenting financial utilization data
  • 6-9 years Patient care or health education in variety of settings
  • 6-9 years Coaching, counseling and administering corrective action
  • Education
  • Bachelor's Health Administration, Management, Nursing, Social Work, or other Health related field Required
  • Master's Health Administration, Management, Nursing, Social Work, or Business Preferred Or equivalent education/experience
  • Licensures and Certifications
  • Registered Nurse - State Licensure - RN Required
  • Other Lean Certification Preferred
  • Other Six Sigma Black Belt Preferred

Potential Telework Position:

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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