This is a fully remote position, open to applicants in Florida.

📋 Description

• Oversee the implementation of medical policies.

• Engage in the development, execution, and assessment of clinical and medical programs.

• Enhance Aetna’s medical management initiatives to meet member needs throughout the continuum of care.

• Assist Medical Management personnel in delivering prompt and consistent responses to both members and providers.

• Supervise utilization review and ensure quality assurance.

• Conduct reviews for predetermination and claims determinations.

• Execute prior authorization, pre-certification, concurrent reviews, peer-to-peer communications, first-level appeals, special projects, and participation in committees.

• Offer expertise in clinical matters, coding, and reimbursement.

• Direct case management as needed.

• Provide clinical insights and business guidance for medical management programs.

• Serve as the primary business and clinical liaison to network providers and facilities.

⛳️ Requirements

• A minimum of five (5) years of experience in the Health Care Delivery System, including Clinical Practice and the Health Care Industry.

• Must possess an active and current state medical license without any encumbrances (Florida preferred).

• Hold an M.D. or D.O. degree.

• Board Certification in a specialty recognized by ABMS or AOA.

• Experience in direct patient care following post-graduate education.

• Previous Utilization Management experience with a Health Plan or Payer is preferred.

🏝️ Benefits

• Bonus, commission, or short-term incentive program through CVS Health.

• Target for awards in the company’s equity award program.

• Comprehensive medical coverage.

• Dental coverage included.

• Vision coverage provided.

• Paid time off available.

• Options for retirement savings.

• Access to wellness programs.

• Additional resources promoting physical, emotional, and financial well-being.