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Aetna Medical Director (Aetna Medicaid) in Richmond, Virginia

Req ID: 62391BR

Job Description

Position Description:

Aetna Medicaid is looking for a Medical Director to be part of a centralized national pool of medical directors that support the Medical Management staff ensuring timely and consistent responses to members and providers related to pre-certification and appeal requests.

The Medical Director 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.

Aetna operates Medicaid managed care plans in sixteen states; Arizona, California, Florida, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Pennsylvania, Texas, Virginia and West Virginia.

The Medical Director is a work-at-home position supporting the Aetna Medicaid line of business in these sixteen states, offering a variety of physical and behavioral health programs and services to its membership.

These positions will primarily support utilization management transactional reviews such as medical and pharmacy prior authorization, including weekend coverage when assigned, as well as appeals and quality of care case reviews.


Minimum of 3 to 5 years of clinical practice experience in the health care delivery field.

Experience with managed care (Medicaid and Medicare preferred) utilization review is required.

M.D. or D.O. Board Certification Active and current state medical license without encumbrances.

Multi-state licensure a plus.

Telework Specifications:

Considered for any US location; training period in the office may be required


This is an opportunity to improve the quality, cost and access to care for members insured by the country's third largest insurer Aetna / a CVS Health Company. The ideal candidate will enjoy working with an innovative and competitive team of clinicians dedicated to the development and consistent application of clinical and payment policies in a rapidly changing healthcare environment. To be successful in this position, the medical director must have excellent skills in desktop software systems such as word processing and spreadsheet applications, as well an ability to work in multiple systems daily. The medical director must be able to function effectively in a complex and challenging decision-making role, applying clinical judgment to do the right thing for the right reasons.

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.

Functional Skills:

Medical Management - Medical Management - Case Management, Medical Management - Medical Management - Clinical claim review, Medical Management - Medical Management - Complaints, Grievance & Appeals, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Precertification

Technology Experience:

Desktop Tool - Microsoft Outlook, Desktop Tool - TE Microsoft Excel, Operating System - Windows

Required Skills:

Benefits Management - Interacting with Medical Professionals, Benefits Management - Maximizing Healthcare Quality, General Business - Applying Reasoned Judgment

Desired Skills:

Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Shaping the Healthcare System, 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.