Executive Director - Medical Director (Medicaid)

CVS Health

27d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: Aetna, a CVS Health Company has an outstanding opportunity for an Executive Medical Director (Medicaid). The Executive Medical Director provides leadership of medical management activities. This person will lead a team of Senior Medical Directors and implement medical management programs/policies. Responsibilities include but can change as business needs dictate: 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. Expands Aetna's medical management programs to address member needs across the continuum of care. Responsibility for reviewing and handling cases when needed Responsibility to be on call when needed.

Requirements

• Strong clinical background with 5+ years of clinical experience in care delivery
• Clinical experience in managed care environment (minimum of 5 years)
• Experience in Utilization Management review and state regulations
• Comfortable finding process improvement areas and leading change
• Ability to identify opportunities to drive process improvements, to lead the change, and ensure the execution
• Experience managing Medical Directors
• Demonstrated knowledge and skills making data driven decisions
• Ability to effectively manage multiple priorities and meet deadlines
• Effective written and oral communication skills with all levels
• Eloquence and finesse when communicating and ability to navigating to diffuse
• Strong strategic thinking and planning
• Five (5) or more years of experience in clinical practice.
• Five (5) or more years administrative experience in the health care industry or managed care.
• M.D. or D.O., Active Board Certification in an ABMS or AOA recognized specialty; including post-graduate direct patient care experience.
• Current and Active State Medical License without encumbrances.

Nice To Haves

• Previous UM experience with a Health Plan or Health / Hospital System.
• Previous Medicaid experience and in the MedCompass, QXNT, CAS and DAG platforms.
• Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts.
• Previous experience with NCQA accreditation

Responsibilities

• 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.
• Expands Aetna's medical management programs to address member needs across the continuum of care.
• Responsibility for reviewing and handling cases when needed
• Responsibility to be on call when needed.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive
• Education Level: Ph.D. or professional degree