• Medical Director (National Accounts)

    AetnaPittsburgh, PA 15222

    Job #945440678

  • Req ID: 61795BR

    Job Description

    POSITION SUMMARY

    The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsor, and regulatory agencies and participates in the strategic medical management for our plan sponsors. The Medical Director will partner with medical management to increase effectiveness of medical management programs and promote integration of other Aetna medical programs.

    This position supports our Commercial Self Insured Plans and provides Medical Management to those Plans.

    Position can be located anywhere in country / Work At Home near an Aetna Office preferred.

    Fundamental Components:

    Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.

    Manage UM transactional work (front line reviews and appeals).

    Build and inspire a culture of continuous improvement for better quality of care.

    Oversee utilization review/quality assurance directing case management.

    Provide UM services based on business demands and shifting business needs

    Partner with medical management leadership to increase effectiveness of medical management programs and to promote the integration of other Aetna medical programs.

    Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.

    Proactively use data analysis to identify opportunities for quality improvement, to positively influence the effective delivery of quality care.

    Work collaboratively with other functional areas that interface with medical management within the National Account Care Management Solutions Team including provider relations, sales, benefits, healthcare delivery, national medical services and national accounts to achieve the business goals of the company.

    Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.

    Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved.

    BACKGROUND/EXPERIENCE

    2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

    1-2 years experience in Clinical leadership (ex. quality review, peer review, group/practice management, hospital teams)

    1-2 years knowledge/experience in managed care (consultant, medical director, discharge planning)

    EDUCATION

    The highest level of education desired for candidates in this position is a MD or DO

    LICENSES AND CERTIFICATIONS

    Medical/Medical License (MD) or (DO) is required

    Medical/Board Certified, National Board Of Medical Examiners is required

    Medical/DEA License is required

    An Active Unrestricted State Medical License is required.

    Active Board Certification in a recognized specialty is required

    FUNCTIONAL EXPERIENCES

    Functional - Medical Management/Medical Management - Direct patient care/4-6 Years

    Functional - Medical Management/Medical Management - Administration/Management/1-3 Years

    Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years

    TECHNOLOGY EXPERIENCES

    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

    REQUIRED SKILLS

    Benefits Management/Interacting with Medical Professionals/ADVANCED

    Leadership/Driving a Culture of Compliance/FOUNDATION

    DESIRED SKILLS

    Benefits Management/Supporting Medical Practice/ADVANCED

    Leadership/Collaborating for Results/FOUNDATION

    TELEWORK SPECIFICATIONS

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

    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.

    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

    Licenses/Certifications:

    Medical - Medical License (for all states)

    Required Skills:

    Benefits Management - Supporting Medical Practice, Leadership - Driving a Culture of Compliance

    Desired Skills:

    Benefits Management - Supporting Medical Practice, Leadership - Collaborating for Results

    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.

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