CVS Health Medical Director (Capitol Market) in Washington, District Of Columbia
Aetna, a CVS Health Company, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 5 company?
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 MD will partner with medical management to increase efficiency 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 Capitol Market, which consists of Commercial and Medicare Advantage health plans in Virginia, Maryland, and DC.
The MD position is a remote-based (work from home) role. Position can be located anywhere in the country; Virginia, Maryland, or DC location is preferred.
In this role you will:
Complete Utilization Management (UM) transactional work (front-line reviews and appeals), which will be 80%-90% of the role.
Build and inspire a culture of continuous improvement for better quality of care.
Oversee utilization review, quality assurance, and case management.
Provide UM services based on business demands and shifting business needs.
Help 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 support 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 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.
Provide clinical guidance in the oversight of our value-based arrangements, including but not limited to accountable care organizations and Medicare collaborations.
MD (Medical Doctor) or DO (Doctor of Osteopathic Medicine)
Licenses and Certifications:
Active, unrestricted state medical license is required; Virginia, Maryland, or DC preferred)
Active Board Certification in a specialty recognized by the American Board of Medical Specialties is required
Family Medicine / Emergency Medicine / Preventive Medicine preferred
At least five (5) years of experience in Health Care Delivery System, e.g., Clinical Practice and Health Care Industry, including at least two (2) years of post-graduate direct patient care experience
Utilization Management experience preferred
Additional Job Information
Work at Home in Virginia, Maryland, or DC preferred, though open to other areas
Participation in virtual meetings with potential for in-person meetings in the future
Occasional weekend coverage
Contribute to population health management and healthcare transformation
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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