Medical Director – Medical Policy & Operations

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

📋 Description

• Delivering clinical expertise to enhance the provision of high-quality, patient-centered medical care with an emphasis on clinical and payment policies.

• Conducting transactional reviews to support the appeals process, clinical claim review, and the predetermination of covered benefits within both Medicare and commercial settings, focusing on Medicare clinical and payment policy.

• Engaging in work groups as a clinical subject matter expert to identify and advocate for opportunities to enhance the quality and efficiency of healthcare services.

• Utilizing clinical, coding, and reimbursement knowledge to ensure compliance and proper application of Aetna policies and practices regarding service and payment requests.

• Actively leveraging data analysis to pinpoint opportunities for quality improvement and to positively affect the effective delivery of quality care services.

• Serving as a subject matter expert, internal consultant, and contributor to payment policy.

• Collaborating effectively with various functional areas.

⛳️ Requirements

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

• Possession of an active and current state medical license without any encumbrances.

• M.D. or D.O. degree with Board Certification in a specialty recognized by ABMS, including post-graduate direct patient care experience.

🏝️ Benefits

• Medical, dental, and vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources, based on eligibility.