Aetna Medical Director in Sugar Land, Texas

Req ID: 52999BR


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 focused medical care with a focus clinical and payment policy. This Medical Director provides subject matter expertise in surgery (preferably orthopedics), ophthalmology, and/or medical oncology to provide clinical support and business direction in these areas. 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 for Commercial and Medicare business, clinical claim review process, precertification, and predetermination of covered benefits. This Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas.


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

In this Role you will:

Provide subject matter expertise in surgery (preferably orthopedics), ophthalmology, and/or medical oncology to provide clinical support and business direction in these areas

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

Be a policy contributor Aetna Clinical Policy Bulletin (Clinical Policy)

Function as subject matter expertise and internal consulting role Payment policy contributor, subject matter expertise and internal consulting role

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 Works collaboratively with other functional areas.


The level of education required for candidates in this position is M.D., or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.


Medical/Medical License (MD) is required

Medical/Board Of Medical Examiners is required


Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/1-3 Years

Functional - Medical Management/Medical Management - Clinical coverage and policies/1-3 Years


Leadership/Driving a Culture of Compliance/FOUNDATION

General Business/Maximizing Work Practices/ADVANCED

Benefits Management/Interacting with Medical Professionals/ADVANCED


General Business/Communicating for Impact/ADVANCED

Telework Specifications:

Full-Time Telework (WAH)


This is an opportunity to improve the quality, cost and access to care for members insured by one of the country's largest private insurer. 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 candidates'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.