Medical Director, Behavioral Health - SIU
About The Position
Aetna, a CVS Health Company, is one of the oldest and largest national insurers. This is a remote based (work from home) full-time position and can be based anywhere in the United States. The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse. The BH Medical Director must be able to travel, as needed, and provide detailed testimony based upon the BH Medical Director’s documentation. The expectation is that the BH Medical Director will have a high level of knowledge when providing testimony during civil and criminal proceedings. The Behavioral Health (BH) Medical Director (Special Investigations Unit) will be responsible for performing reviews of BH medical records and/or CPT code/HCPCS codes of known or suspected acts of healthcare fraud and abuse.
Requirements
- Five (5) or more years of experience in a healthcare delivery system (e.g., clinical practice)
- Board Certified Psychiatrist not "Board Eligible"
- Active and Unencumbered license to practice medicine
- Knowledge of pertinent policies and procedures related to claims payment of healthcare related services.
- M.D. or D.O., Board Certification in psychiatry, including 5 years of post-graduate direct patient care experience.
Nice To Haves
- 2 years’ experience within health care industry/knowledge of CPT and HCPCS coding guidelines and principles
- Psychiatric experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
- Psychiatric experience in providing clinical guidance and input in the business analytic building process.
- Child and Adolescent Psychiatrist
Responsibilities
- Serves as a clinical liaison supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
- Provides clinical expertise and consultation in the creation of data analytic monitors to identify potential patterns of suspected fraud, waste or abuse.
- Provides consultation to staff regarding root cause analysis and identification of control gaps in Policies, Procedures, Claims edits etc., and assists in seeking appropriate departments to identify solutions.
- Provides clinical expertise to internal and customers regarding healthcare fraud matters and Aetna's approach to fighting fraud.
- Maintains open communication with constituents within the company.
- Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
- Researches and prepares cases for clinical and legal review
- Documents all appropriate information related to medical record review determinations.
- Represents Aetna as a witness in court actions, as required, and as approved by Legal.
- Is responsible for Peer-to-Peer Reviews of SIU related claims in states that mandate such review
- Exhibits behaviors outlined in Employee Competencies.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
