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Aetna Senior Director, Medical Health Services (Heartlands Region) in Denver, Colorado

Req ID: 61543BR

Job Description

Position Description:

The Senior Director for the Heartlands Region provides leadership of medical management activities. This person will lead a team of Medical Directors and implement medical management programs/policies.

The Heartlands Region consists of KS / Western MO / ND / NE / CO / Northwest AR / Parts of CO

Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes.

Direct the utilization review process and oversee the quality of utilization determinations.

Ensure compliance with clinical goals through monitoring care management performance.

Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff.

Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.

Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.

Leads clinical staff in the coordination of quality care 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 teams

Responsibility for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise Expands Aetna's medical management programs to address member needs across the continuum of care

Background / Experience:

3-5 years experience in the health care delivery system e.g., clinical practice and health care industry.

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.


Medical - Medical License (for all states)

Functional Skills:

Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - General Management, Medical Management - Medical Management - Clinical coverage and policies

Technology Experience:

Desktop Tool - Microsoft Exchange, Desktop Tool - Microsoft Explorer, Desktop Tool - TE Microsoft Excel

Required Skills:

Leadership - Collaborating for Results, Leadership - Creating Accountability, Leadership - Driving a Culture of Compliance, Service - Improving Constituent-Focused Processes

Desired Skills:

Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts

Benefit Eligibility

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

Job Function: Healthcare

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.