Medical Director

This is a fully remote position, open to applicants in Illinois, +3 more states.

📋 Description

• Oversee the implementation of medical policies

• Engage in the creation, execution, and assessment of clinical and medical initiatives

• Enhance Aetna's medical management programs to meet member requirements throughout the continuum of care

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

• Supervise utilization review and quality assurance processes

• Conduct predetermination reviews and evaluations of claim decisions

• Execute prior authorization, pre-certification, concurrent reviews, peer-to-peer communications, and first-level appeals

• Participate in special projects and committees as required

• Offer expertise in clinical matters, coding, and reimbursement

• Direct case management when deemed necessary

• Supply clinical knowledge and business guidance by engaging in clinical team activities

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

• Facilitate the effective implementation of medical services programs by clinical teams

⛳️ Requirements

• A minimum of five (5) years of experience in a healthcare delivery system, including clinical practice and the healthcare industry

• An active and unencumbered medical license in one of the Midland States (IL, MO, MN, WI)

• M.D. or D.O. degree

• Valid and current board certification in a specialty recognized by ABMS or AOA

• Post-graduate direct patient care experience

• Prior experience in utilization management within a health plan, payor, or as a physician advisor in a healthcare system is preferred

• Board certification in Internal Medicine, Family Medicine, Emergency Medicine, Med/Peds, or General Surgery is preferred

🏝️ Benefits

• Medical, dental, and vision insurance

• Paid time off

• Retirement savings plans

• Wellness initiatives

• Additional resources promoting physical, emotional, and financial wellness

• CVS Health bonus, commission, or short-term incentive program

• Equity award program