Aetna Medical Director (Medical Policy & Operations) in Atlanta, Georgia

Req ID: 55916BR

POSITION SUMMARY

The Medical Director MPO (Medical Policy & Operations) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus clinical and payment policy. Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.

Fundamental Components:

Basic responsibilities of this Medical Director include support of the appeal process, clinical claim review process, precertification, and predetermination of covered benefits in the commercial and Medicare environment. This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas.

In this role you will:

Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services.

Apply clinical coding and reimbursement expertise to insure alignment and correct application of Aetna policies and practices to service and payment requests.

Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services.

Work on the Aetna Clinical Policy Bulletin (Clinical Policy) as a policy contributor.

Be a subject matter expert and internal consultant and payment policy contributor subject matter expertise and internal consultant.

Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company.

Work Collaboratively with the functional areas.

Required Skills:

Interacting with Medical Professionals

Maximizing Work Practices

Driving a Culture of Compliance

BACKGROUND/EXPERIENCE

2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

M.D. or D.O.

Foundational baseline skills include Medicine, Health Policy, Epidemiology, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems.

Strong communication skills both written and verbal.

EDUCATION

The highest level of education desired for candidates in this position is a MD or DO.

LICENSES AND CERTIFICATIONS

Medical License (MD/DO) - required

Board Certification in Aetna Recognized Specialty (ABMS or AOA) is required

Active and current state medical license without encumbrances.

FUNCTIONAL EXPERIENCES

Functional - Medical Management - Clinical coverage and policies 1 to 3 years

Functional - Medical Management - Complaints, Grievance & Appeals 1 to 3 years

Functional - Medical Management - Coding 1 to 3 years

Functional - Medical Management - Clinical Claim Review 1 to 3 years

TECHNOLOGY EXPERIENCES

Technical - Aetna Applications///

REQUIRED SKILLS

Benefits Management/Interacting with Medical Professionals/ADVANCED

General Business/Maximizing Work Practices/ADVANCED

Leadership/Driving a Culture of Compliance/FOUNDATION

Telework Specifications:

Considered for any US location; training period in the office may be required

ADDITIONAL JOB INFORMATION

This is an opportunity to improve the quality, cost and access to care for members insured by the country's third largest insurer Aetna / a CVS Health Company. The ideal candidate will enjoy working with an innovative and competitive team of clinicians dedicated to the development and consistent application of clinical and payment policies in a rapidly changing healthcare environment. To be successful in this position, the medical director must have excellent skills in desktop software systems such as word processing and spreadsheet applications, as well an ability to work in multiple systems daily. The medical director must be able to function effectively in a complex and challenging decision-making role, applying clinical judgment to do the right thing for the right reasons.

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

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.