Medical Director – Medicaid

This is a fully remote position, open to applicants in Florida, +2 more states.

📋 Description

• Provide support to Aetna Better Health of Louisiana and additional health plans as required.

• Collaborate with Medical Management personnel to guarantee timely, consistent, and clinically appropriate decisions for both members and providers.

• Conduct Utilization Management and assessments of medical necessity.

• Make determinations regarding prior authorizations and precertifications.

• Carry out concurrent reviews for both inpatient and outpatient services.

• Execute reviews for acute and post-acute care.

• Facilitate peer-to-peer consultations with healthcare providers involved in treatment.

• Conduct pharmacy reviews and make first-level appeal determinations.

• Work alongside multidisciplinary clinical and operational teams.

• Engage in a rotating on-call schedule that includes weekend and holiday duties.

⛳️ Requirements

• Possession of an active, unrestricted medical license in Louisiana.

• Capability to obtain licensure in Florida and Kentucky.

• A degree as an M.D. or D.O.

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

• At least 5 years of clinical practice and direct patient care experience following residency.

• Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.

• Previous experience in Utilization Management within a health plan, managed care organization, Independent Review Organization, or as a Physician Advisor.

• Experience with Medicaid and managed care systems.

• Familiarity with medical necessity reviews, prior authorizations, concurrent reviews, appeals, and peer-to-peer consultations.

• Proficiency in utilizing electronic health records and other clinical documentation platforms.

🏝️ Benefits

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

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off benefits.

• Options for retirement savings.

• Wellness initiatives.

• Additional resources aimed at supporting physical, emotional, and financial wellness.