Aetna Medical Director (Aetna Better Health of Virginia) in Richmond, Virginia
Req ID: 50691BR
Aetna Better Health of Virginia, Inc. (ABHVA) is hiring a Medical Director, for our Integrated Care Program for Medicaid and Long Term Systems and Supports members within the Commonwealth. You will implement and supervise delivery and coordination of all services and benefits under the contract between Aetna Better Health (ABH), the Virginia Department of Medical Assistance Services, and CMS. DMAS stated, Virginia envisions a Medicaid delivery system where high value care is the norm and even the most medically complex enrollees with significant behavioral, physical, sensory, and developmental disabilities can live safely and thrive in the community.
ABHVA shares this vision to create a transformational system supporting all Medicaid and MLTSS members, with the highest quality care in the least restrictive environment manner. Integrated Care Management accomplishes this objective by integrating physical and behavioral health, addressing social determinants of health, and minimizing the complexity and fragmentation of services. Fundamental to the Fully Integrated System of Care and Integrated Care Management is ongoing collaboration and alignment among all internal and external stakeholders.
In this role you will:
Provide collaborative oversight for medical policy implementation and utilization management services.
Participate in the development, implementation, and evaluation of clinical/medical programs.
Provide health leadership, oversight and consultation for the QI and UM programs including development, implementation, evaluation and compliance.
Oversee the utilization review process and oversee the quality of utilization determinations.
Ensure compliance with clinical goals through monitoring care management performance.
Develop, implement and interpret medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments.
Promote the Bio-Psycho-Social model for integrated care management.
Under the direction of the Chief Medical Officer (CMO), Review prior authorizations for medical necessity.
Under the direction of the Chief Medical Officer (CMO) recruit, train, supervise and evaluate the quality of medical staff and any physician advisors.
Participate regularly in the Interdisciplinary Care Management Rounds.
Serve as a subject matter expert and liaison with State Medicaid and CMS leadership.
Coordinate collaborative relationships with Community Mental Health Centers (CMHCs), Federally Qualified Healthcare Clinics (FQHCs) and various Advocacy Groups.
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
The highest level of education desired for candidates in this position is an MD or DO.
Utilization review and accreditation (NCQA, AAHCC/URAC) experience preferred.
Medical Degree (MD or DO) from accredited (ACME or AOA) American or Canadian medical school or equivalent training in a foreign medical school with successful completion of ECFMG and FLEX exams.
Full training in a ACGME approved U.S. or Canadian residency program.
MBA, MHA, MPA or advanced management training a plus.
LICENSES AND CERTIFICATIONS:
Board Certification in Geriatrics, Family Medicine, Internal Medicine, or Emergency Medicine is desired
Active unrestricted License to practice Medicine in the state of Virginia is required or ability to obtain a license in the state of Virginia.
5-8 years of experience involving substantial direct patient care at multiple levels of care.
Experience with Medicaid and Medicare policies and regulations.
Managed care experience, as provider and manager of care.
Managed Care Experience as a Medical Director preferred, willing to train if no prior managed care experience
Experience with MLTSS or Duals Eligible Population preferred.
Familiarity with Networks in the Virginia area preferred but not required.
Experience in interacting with various Aged, Blind and Disabled (ABD) Advocacy Groups is a plus.
Benefits Management: Interacting with Medical Professionals and Maximizing Healthcare Quality
Service: Improving constituent-focused Processes
Leadership: Collaborating for Results and Driving a Culture of Compliance
General Business: Maximizing Work Practices
Mostly office based in Richmond but open to part-time telework or location near other of our Virginia regional offices.
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