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.
•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
•Facilitates educational training for medical staff on issues related to utilization management.
•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
66907 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:
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