Aetna Medical Director in Blue Bell, Pennsylvania
Req ID: 50341BR
Operating with a balance of internal and external-facing activities that support a shift to a higher-touch, patient-centric focus, the Medical Director will develop, implement, support, and promote population health strategies, tactics, policies, and programs that drive the delivery of high value healthcare to establish a sustainable competitive business advantage for Aetna. These strategies, policies, and programs are comprised of care management, utilization management, quality improvement, network management as well as clinical coverage protocol. The Medical Director will be provider facing and have fluency in data analytics.
Central Pennsylvania Location preferred. Work at Home position after initial training completed.
Supports the Medical Management staff ensuring timely and consistent responses to members and providers.
Oversees utilization review/quality assurance, directing case management
Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities
Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teamsResponsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise
Ability to collaborate with all stakeholders, understanding the guidelines/basics (how to access) the requirements, opportunities to shape within the scope in the role as a Health plan medical director.
Analytics-Oriented Care: Ability to analyze data (e.g., medical cost trends) and articulate trend and solutions. Ability to manage complex cases and client relationships with plan sponsors. Proactive Virtual and Physician Engagement: Leveraging multi-channel platforms and digital technology to interface with internal and external customers in virtual and physical settings.
End to End Market Understanding: Strong business acumen. Understands and proficient articulating products, financial impacts and market demands. Consultant and supplier of actionable information. Expertise in market/state DOL regulations delivering HEDIS/STARS consultation.
Communications: Both oral and written skills and comfort in presenting to varied groups. Building and fostering relationships and partnering with the external community and providers in a pro-active approach to population health. Using data analytics to inform and influence population health to drive behavior change and expand Aetna's medical management programs to address specific member conditions across the continuum of care.
Collaborating with the Medical Management staff both internally and externally ensuring timely and consistent responses to members and providers. Providing clinical expertise and business direction in support of medical management programs through active collaboration and participation in clinical team activities.
Acting as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. Occasionally attend & engage in Sales presentation meetings providing the value prop/story behind the partnerships
Executing predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise. Manage UM transactional work(front line reviews and appeals).
Building and inspiring a culture of continuous improvement for better quality of care.
Creating products that utilize patient engagement in a new and effective manner utilizing tools and analytics.
Overseeing utilization review/quality assurance directing case management. Provide UM services based on business demands and shifting business needs
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
The highest level of education desired for candidates in this position is a MD or DO.
LICENSES AND CERTIFICATIONS:
Medical/Medical License - Pennsylvania is desired
M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.
Active and current state medical license without encumbrances
Functional - Medical Management/Medical Management - Administration/Management/1-3 Years
Functional - Medical Management/Medical Management - Concurrent Review/1-3 Years
Functional - Medical Management/Medical Management - Physician Relations/1-3 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years
Functional - Clinical / Medical/General Management/1-3 Years
Technical - Desktop Tools/Microsoft Exchange/1-3 Years/End User
Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/End User
Technical - Desktop Tools/Microsoft Word/1-3 Years/End User
Technical - Desktop Tools/TE Microsoft Excel/1-3 Years/End User
Benefits Management/Interacting with Medical Professionals/ADVANCED
Leadership/Collaborating for Results/FOUNDATION
Leadership/Driving a Culture of Compliance/FOUNDATION
Benefits Management/Maximizing Healthcare Quality/ADVANCED
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Communicating for Impact/ADVANCED
Geographic preference is for Central PA location
ADDITIONAL JOB INFORMATION
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