Aetna Medical Director (Medicare Advantage - Telecommute) in Los Angeles, California

Req ID: 45510BR


Job responsibilities are related to Medicare Appeals

Fundamental Components:

Direct daily work on part C appeals (both provider and member/non-participating providers) and part D appeals; provide direct support to appeal nurses and dedicated Medicare part D pharmacists

Supervision and participation in the Second Look Review (SLR) process; provide direct support to the SLR nurses

Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work

IRE monitoring and tracking and director on an intermittent basis with the Aetna IRE team

STARS support through appeals work

Utilization Management Strategy support

Collaborative work with Medicare Quality and Compliance on an ongoing basis

Development subject matter expertise on Medicare policy for the enterprise

Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management staff

Participate in ongoing ABX initiatives to improve Appeals team efficiency and clinical consistency


2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.


The highest level of education required for candidates in this position is a MD.


Medical/Medical License (MD/DO) is required


Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/4-6 Years


Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Job Function: Health Care