Medical Director (Ortho/Total Joint)
About The Position
Aetna, a CVS Health Company, is a national insurer aiming to transform healthcare by making it more transparent and consumer-focused, recognizing physicians for their clinical quality and effective use of health care resources. This is a remote-based role 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 role supports Aetna's medical management programs across the continuum of care, assisting Medical Management staff with timely responses to members and providers. Key responsibilities include leading utilization review/quality assurance, directing case management, providing clinical expertise and business direction to clinical teams, and acting as a liaison to network providers and facilities. The role also involves predetermination reviews and reviews of claim determinations, 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.
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
