Aetna Sr. Director - Chief Medical Officer Aetna Better Health of Pennsylvania - 44439BR in Wimington, Delaware
Req ID: 44439BR
The Senior Director Medical Health Services (CMO) for Aetna Better Health of Pennsylvania will lead the Medical Management Department of a PA Medicaid MCO. As the Chief Medical Officer you are a member health plan leadership team and responsible for all aspects of the health plan's Medical Management department.
Potential to work at home 1 -2 days per week once fully trained. Candidates within a commutable range from Philadelphia welcome: New Jersey, Upper Maryland, Delaware and Eastern Pennsylvania.
Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes.
Direct the utilization review process and oversee the quality of utilization determinations. Ensure compliance with clinical goals through monitoring care management performance.
Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff.
Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
Leads clinical staff in the coordination of quality care .
Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Responsibility for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
Expands Aetna's medical management programs to address member needs across the continuum of care
15+ years experience in the health care delivery system e.g., clinical practice and health care industry.
5-10 Years Managed care experience (Medicaid experience preferred)
The highest level of education desired for candidates in this position is a MD or DO
LICENSES AND CERTIFICATIONS
Active / Unrestricted Medical License - Pennsylvania is desired
Functional - Medical Management/Medical Management - Concurrent Review/4-6 Years
Functional - Management/Management - Multifunctional management :> 25 employees/4-6 Years
Functional - Leadership/Lead a complex or multifunctional organization/4-6 Years
Leadership/Collaborating for Results/MASTERY
Leadership/Driving a Culture of Compliance/MASTERY
Leadership/Developing and Executing Strategy/MASTERY
General Business/Communicating for Impact/MASTERY
General Business/Turning Data into Information/MASTERY
Leadership/Creating a World Class Workforce/MASTERY
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.
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