Medical Director (Ortho/Total Joint)

CVS Health•Work At Home-Connecticut, CT

7d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health Company, is a national insurer with a unique opportunity to transform health care. This role is a remote-based position anywhere in the US. The Medical Director (Ortho/Total Joint) will serve as a Subject Matter Expert (SME) with a background in Orthopedics, including post-graduate direct patient care experience. This position supports Aetna's medical management programs across the continuum of care, ensuring timely and consistent responses to members and providers. The role involves leading utilization review/quality assurance, directing case management, and providing clinical expertise and business direction to clinical teams. Additionally, the Medical Director will act as a liaison to network providers and facilities, and be responsible for predetermination reviews and claim determination reviews, offering clinical, coding, and reimbursement expertise.

Requirements

2 or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
Active and current state medical license without encumbrances.
M.D. or D.O., Board Certification in an Orthopedic specialty including post-graduate direct patient care experience specifically.

Nice To Haves

Previous healthcare insurance experience.

Responsibilities

Support the Medical Management staff ensuring timely and consistent responses to members and providers.
Lead all aspects of utilization review/quality assurance.
Direct case management.
Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Act 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 and reviews of claim determinations, providing clinical, coding, and reimbursement expertise.