Medical Director - Medical Policy & Operations
November 21
Description
• Responsible for providing clinical expertise and business direction in medical management programs • Support the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits • Participate on work groups as a clinical subject matter expert to improve healthcare quality and efficiency • Apply clinical coding and reimbursement expertise to align Aetna policies to service requests • Proactively use data analysis for quality improvement opportunities
Requirements
• Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry • Active and current state medical license without encumbrances • M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience • Health plan/payor experience preferred • Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems preferred • Experience with DRG reviews preferred • Prior hospitalist experience preferred • Strong communication skills both written and verbal preferred
Benefits
• Full range of medical, dental, and vision benefits • Eligible for 401(k) retirement savings plan • Employee Stock Purchase Plan available • Fully-paid term life insurance plan • Short-term and long term disability benefits • Well-being programs and education assistance • Free development courses • CVS store discount and partner discount programs • Paid Time Off (PTO) or vacation pay • Paid holidays throughout the year
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