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
The Medical Director is part of a team of Medical Directors supporting various Markets throughout the country. Ohio and Kentucky location Preferred but not Required.
- 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
- Lead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits.
- Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (e.g. telephonic rounds) in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management.
- 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 overall value improvement (including both financial as well as quality improvement), to positively influence the effective delivery of quality care.
- Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.
- 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.
- 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
- Internal Medicine / Family Medicine / Emergency Medicine preferred
- 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
- 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
- Benefits Management/Interacting with Medical Professionals
- Leadership/Driving a Culture of Compliance
- Benefits Management/Supporting Medical Practice
- Leadership/Collaborating for Results
- Work at Home with Kentucky or Ohio preferred though open to other locations