Aetna Medical Director - Aetna Better Health of Florida in Sunrise, Florida
Req ID: 49614BR
Aetna Better Health of Florida (an Aetna Medicaid Plan) is looking for a Medical Director to develop, implement, support, and promote Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies
Provide oversight for medical policy implementation. Participate in the development, implementation, and evaluation of clinical/medical programs.
Expands Aetna's medical management programs to address member needs across the continuum of care.
Supports the Medical Management staff ensuring timely and consistent responses to members and providers.
Oversees utilization review/quality assurance, directing case management.
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.
Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Previous experience working in a managed care setting on the payer / insurer side highly desirable.
The highest level of education desired for candidates in this position is an MD. or DO.
LICENSES AND CERTIFICATIONS
Active and unrestricted state medical license is required. Active and Current Board Certification in recognized medical specialty required.
Medical License - Florida is desired
Functional - Medical Management/Medical Management - Administration/Management/1-3 Years
Functional - Medical Management/Medical Management - Case Management/1-3 Years
Functional - Medical Management/Medical Management - Clinical claim review/1-3 Years
Functional - Medical Management/Medical Management - Concurrent Review/1-3 Years
Functional - Medical Management/Medical Management - Complaints, Grievance & Appeals/1-3 Years
Technical - Desktop Tools/Microsoft Outlook/1-3 Years/
Technical - Desktop Tools/Microsoft PowerPoint/1-3 Years/
Technical - Desktop Tools/Microsoft SharePoint/1-3 Years/
Technical - Desktop Tools/Microsoft Word/1-3 Years/
General Business/Demonstrating Business and Industry Acumen/ADVANCED
Leadership/Collaborating for Results/FOUNDATION
Service/Improving constituent-focused Processes/ADVANCED
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
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.