Medical Director – Commercial

Role Overview

• Provide oversight for medical policy implementation.
• Participate in the development, implementation, and evaluation of clinical / medical programs and expand Aetna's medical management programs to address member needs across the continuum of care.
• Support the Medical Management staff ensuring timely and consistent responses to members and providers.
• Focus primarily on overseeing utilization review / quality assurance and be responsible for predetermination reviews and reviews of claim determinations.
• This includes Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / First Level Appeals / Special Projects and Committee participation when needed.
• Provide clinical, coding, and reimbursement expertise as well as directing case management when necessary.
• Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
• Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Requirements

• 2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
• Active and current medical license without encumbrances
• M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.
• Five or more years of direct patient care experience preferred
• Preferred licensed in TX, CA, or FL
• Previous UM experience with a Health plan/payor experience.
• Electronic medical systems/record experience
• Managed Care experience
• Board certification in Internal Medicine, Family Medicine, Emergency Medicine, or Med/PM&R Education
• Active and current state medical license without encumbrances

Benefits

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• Employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.