Aetna Medical Director (Great Lakes Region) in Chicago, Illinois
Req ID: 52339BR
The Medical Director for the Great Lakes Region will develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Provide oversight for medical policy implementation. Participate in the development, implementation, and evaluation of clinical/medical programs.
Work at Home position once training is completed / MI, IN, IL, MN, WI, IA, NE, MO, SD, ND, MN, CO.
Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
Manage UM transactional work (front line reviews and appeals).
Build and inspire a culture of continuous improvement for better quality of care.
Oversee utilization review/quality assurance directing case management.
Provide UM services based on business demands and shifting business needs
Lead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits.
Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (eg. telephonic rounds) in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management.
Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.
Proactively use data analysis to identify opportunities for overall value improvement (including both financial as well as quality improvement), to positively influence the effective delivery of quality care.
Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.
Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.
Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved.
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Previous experience in Managed Care specifically Medicare Preferred but not required.
The highest level of education desired for candidates in this position is a MD or DO.
LICENSES AND CERTIFICATIONS
Board Certification in a recognized specialty required
Active and current state medical license without encumbrances required
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 Explorer/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
MI, IN, IL, MN, WI, IA, NE, MO, SD, ND, MN, CO.
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
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.