Skip to main content

Senior Director, Clinical Solutions Medical Director

Primary Location: Phoenix, AZ
Additional Locations: AZ-Phoenix
Apply
Description:
The Senior Director, Clinical Solution Medical Director is accountable for the planning, organizing, and directing of the medical director support for the health plan Utilization Management activities. The Senior Director is responsible for operational oversight and medical director coverage for Prior Authorization, Concurrent Review, Peer-to-Peer support, Grievance and Appeals, and Medical Claims Review, to ensure compliance with regulatory, contractual and accreditation requirements. Role is responsible for the planning and growth of the department to meet current and future needs of the organization. The success of this position requires the ability to foster communication and teamwork among physicians, health plan medical management staff, shared service departments, vendors, and senior leadership.

Primary Responsibilities:
General essential functions include responsibility for oversight of medical directors to ensure appropriate and timely utilization management activities for day-to-day operations, i.e. prior authorization, concurrent review, peer-to-peer and appeal reviews are efficient, accurate, and progressive.
Fosters collaboration works cohesively together within the health plan Chief Medical Officer and utilization management clinical staff to positively impact utilization trends and cost.
Responsible for significant contributions ideation and pipeline development through rigorous evaluation of underlying medical spend for emerging trends and costs, etc.
Oversees creation of infrastructure and parameters for work streams in coordination with health plan utilization management teams or outside vendors
Oversees outside medical services based on Health Plan benefit guidelines and medical necessity.
Completes analyzes and reports significant utilization trends, patterns, and impact along with recommendations on interventions to resolve negative trends to the health plan CMO and appropriate medical staff committees.
Develops and communicates performance metrics and expectations
Assures compliance with Federal, State, NCQA, other regulatory agencies and internal standards and requirements.
Ensure clinical review standards are maintained and productivity is optimized through effective training and quality medical reviews
Identify opportunities for increased operational effectiveness and efficiency
Hires, coaches, trains and disciplines staff to ensure smooth operations in
utilization management.
Facilitates educational training for medical staff on issues related to utilization management.

Requirements:
3+ years in healthcare business management, managed care or health plan management
5+ years demonstrated staff management experience
Excellent knowledge of health care industry. Preferred industry depth in a Medicare and/or Medicaid line of business
Strategic thinking with proven ability to communicate a vision and drive results
Knowledge of Medicaid managed care utilization management operations and healthcare management
Excellent interpersonal communication skills; ability to influence in executive settings and provide constructive feedback
Ability to optimize resources using excellent judgment, and an attitude that fosters teamwork and supports organizational goals
Strong team player and team building skills
Creative problem-solving skills
Proficiency with Microsoft Office applications (Outlook, Word, Excel, PowerPoint)

Education / Licenses:
Current unrestricted medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
Master's degree in business or related field, Preferred
Board Certification in Aetna Recognized Specialty required


Additional Job Information:
Demonstrated comfort with rapidly changing technology for engagement and analytics.Demonstrated transformation/change management skills and experience.Demonstrated leadership qualities that inspire and develop others.Commitment to coaching and collaborating.Exceptional oral and written communication skills.

Functional Skills:
Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - General Management, Clinical / Medical - Management: < 25 employees, Clinical / Medical - Precertification, Medical Management - Medical Management - Managed Care/Insurance Clinical Staff

Technology Experience:
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Visio, Desktop Tool - Microsoft Word

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.

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.

Apply

Jobs for you

Recently Viewed Jobs

You do not have any recently viewed jobs

Your Saved Jobs

You do not have any saved jobs

Sign up for Job Alerts

Join our Talent Community

At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna.

Join Our Talent Community

Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna.