Aetna Medical Director (Aetna Better Health of KY) in Lexington, Kentucky
Req ID: 67916BR
Aetna Better Health of Kentucky (an Aetna Medicaid Plan) is looking for a Medical Director to 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.
Work at Home position after initial training. Preferred Medical Specialties include Internal Medicine / Emergency Medicine / OB GYN and / or Surgical experience. Managed Care Experience with a Health Plan / Payer Highly Desirable.
Pre-certification review and determination (Physical Health, Pharmacy)
Health Plan Rounds (IDT/UM Support)
Appeals support (with health plan CMOs)
Clinical claims review
Provide oversight for medical policy implementation. Participate in the development, implementation, and evaluation of clinical/medical programs.
Expands Aetna's medical management programs to address member needs across the continuum of care.
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 teams.
Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
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:
Active unrestricted KY state medical license required or ability to get a KY license
Board Certification in Aetna recognized specialty required
Functional - Medical Management/Medical Management - Case Management/1-3 Years
Functional - Medical Management/Medical Management - Disease management/1-3 Years
Technical - Desktop Tools/Microsoft Outlook/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
Leadership/Collaborating for Results/FOUNDATION
General Business/Communicating for Impact/ADVANCED
General Business/Turning Data into Information/ADVANCED
General Business/Demonstrating Business and Industry Acumen/ADVANCED
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 candidates 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.
Clinical / Medical - Clinical claim review & coding, Clinical / Medical - Concurrent review / discharge planning, Clinical / Medical - Precertification, Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Clinical coverage and policies, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Discharge planning
Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word
Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, Benefits Management - Understanding Clinical Impacts, General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen, General Business - Maximizing Work Practices, Service - Case Administration, Service - Creating a Differentiated Service Experience, Service - Demonstrating Service Discipline, Service - Improving Constituent-Focused Processes
General Business - Maximizing Work Practices, Leadership - Collaborating for Results, Leadership - Creating Accountability, Leadership - Driving a Culture of Compliance
Benefit eligibility may vary by 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.