CVS Health Medical Director in Richfield, Ohio
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 the Ohio and Kentucky markets for Aetna's Commercial and Medicare lines of business. .
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.
Two (2) to Three (3 ) 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 a Aetna recognized specialty including post-graduate direct patient care experience (ABMS)
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.
Percent of Travel Required
0 - 10%
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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