Aetna Senior Medical Director in Falls Church, Virginia
Req ID: 62382BR
Provide leadership of medical management activities. Develop and implement medical management programs/policies.
· Develops relationships with provider partners, learns about their priorities, and develops provider-driven solutions to reducing cost, improving quality and improving member experience. Participates in Joint Operating Committee and medical management discussions with provider partners, and clinical workgroups.
· Analyzes cost, utilization and quality data and compares against best practices to understand key drivers and opportunities. Validates analysis with medical record review and clinical judgment.
· Learns Aetna processes for medical management processes and initiatives such as utilization management and virtual care and brings physician perspective to how they could be leveraged and/or improved by the joint ventures.
· Provides physician support to JV care management teams.
Fundamental Components included but are not limited to:
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
Qualifications Requirements and Preferences:
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.
Additional Job Information:
Location can be either Northern VA or MN - FT WAH
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.