Aetna Medical Director 41512BR in Sunrise, Florida
Req ID: 41512BR
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 sponsors, and regulatory agencies. The MD is a partner and tightly integrated with the local market team
Promote quality, cost effective 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 in the execution of precertification, concurrent review/discharge planning, appeals, case management, disease management, and quality management. Including direct participation with plan sponsors, providers, facilities and vendors as required - 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 - Act as the lead business and clinical liaison to network providers and facilities to support effective execution of the medical services programs by the clinical teams - Participate in quality management activities at regional and market levels including those necessary to achieve NCQA and URAC accreditation - Proactively uses data analysis to identify opportunities for quality improvement and to positively influence the cost effective delivery of quality care - Leverage the use of predictive modeling and medical cost forecasting capabilities to improve decision making relative to medical cost spending - 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 including provider relations, contracting, member services, sales, benefits and claims management, healthcare delivery, national medical services and national accounts to achieve the business goals of the company - Lead clinical staff in assuring members' care is coordinated in a fashion that achieves the most value for the available benefits, and that a liaison is available to the members' caregiver for coordination of benefits - Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general -Acts to engage providers and facilities in improving the cost and quality of care delivered to our members and assures that our shared business relationships are maintained and improved
-2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
-Demonstrated appreciation of cultural diversity and sensitivity towards target populations
The highest level of education desired for candidates in this position is a MD.
LICENSES AND CERTIFICATIONS
Medical Management/ABMS/AOA - Internal Medicine is desired
Medical/American Board of Internal Medicine is desired
Functional - Medical Management/Medical Management - Clinical coverage and policies/4-6 Years
Functional - Clinical / Medical/Concurrent review / discharge planning/4-6 Years
Functional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years
Functional - Clinical / Medical/Precertification/4-6 Years
Functional - Medical Management/Medical Management - Managed Care/Insurance Administration/1-3 Years
Benefits Management/Understanding Clinical Impacts/ADVANCED
General Business/Demonstrating Business and Industry Acumen/ADVANCED
Leadership/Driving a Culture of Compliance/FOUNDATION
General Business/Turning Data into Information/ADVANCED
ADDITIONAL JOB INFORMATION
Will work closely with our local market business leaders to engage providers and facilities. The Medical Director is a critical part of the team providing value to the markets we serve. 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.
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 candidate's 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.
Job Function: Health Care