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Senior Director, Medical Management Services

Primary Location: Plantation, FL
Additional Locations: FL-Plantation
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Description:
Sets the strategic direction, planning, budgeting, coordination and oversight of health plan medical management functions for all lines of business.



Fundamental Components:

Collaborates with executive leadership throughout the organization to develop and implement program strategies that meet business, CMS, federal and state regulations as well as accrediting agency requirements. Creates and maintains collaborative partnerships with key accounts (large medical groups, hospital providers); works to establish collaborative relationships by fostering excellent customer response and appropriate problem resolution. Leads a team that promotes high standards of operational practice through advancement of policies, procedures, practice guidelines andalignment of clinical and business processes and practices. Responsible for cross-functional integration of care and case management, utilization management, program operations with core organization-wide business functions including claims, member services, compliance, quality and network/provider services. Responsible for cost savings and quality improvement projects through successful implementation. Leads and manages all aspects of projects and/or programs. Ensures the use of a formal project plan and collaborative workgroups are used in demonstrating the achievement of the project implementation goals. Responsible for the implementation and revision of medical management letters ensuring that letters are compliant, federal and state regulations as well as accrediting entities. Consults and supports the utilization management processes by encouraging the use of industry best practices and standards. Responsible for relationship management for vendors; ensures targets are achieved and medical management goals are met.



Background Experience:
10+ years of experience in managed care preferred
5+ years management or clinical leadership (Reporting structure 25+ employees)
Responsible for developing adherence to budget and financial acumen & reporting.
5+ years clinical practice experience in physical or behavioral healthcare.
Knowledge of medical management regulations, standards, and policies. Medicaid, long term care, CHIP and Medicare.

EDUCATION
Master's degree in behavioral health field

LICENSE
Active unrestricted Florida State Licensure in applicable functional area. (e.g. RN, LMFT, LPC, LCSW).

Additional Job Information:
Ability to synthesize program performance and clinical outcomeAbility to evaluate and interpret data for the purpose of developing new programs and processes to meet business demandsAbility to communicate in a highly effective manner with internal and external constituents in both written and oral format

Required Skills:
Leadership - Anticipating and Innovating, Leadership - Collaborating for Results, Leadership - Developing and Executing Strategy, Leadership - Driving a Culture of Compliance

Desired Skills:
Benefits Management - Maximizing Healthcare Quality, Leadership - Driving Strategic and Organizational Agility, Leadership - Engaging and Developing People, Technology - Leveraging Technology

Functional Skills:
Clinical / Medical - Management: > 25 employees, Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Clinical coverage and policies, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Legislative and regulatory compliance

Technology Experience:
Desktop Tool - Adobe Acrobat Suite v5, Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft PowerPoint, Desktop Tool - TE Microsoft Excel

Education:
Mental Health - Licensed Clinical Social Worker, Mental Health - Licensed Professional Counselor, Nursing - Registered Nurse

Potential Telework Position:
No

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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