Medical Director-Medicaid (ABH VA)
About The Position
This is a full-time, fully remote physician leadership role supporting Aetna Better Health of Virginia, with additional support for the Northeast Region (Maryland, New Jersey, New York, and Pennsylvania) and other health plans as needed. The Medical Director joins the centralized Medical Management team and partners with staff to ensure timely, consistent, and clinically sound decisions for members and providers. The role requires an active, unrestricted Virginia medical license and participation in a rotating on-call schedule that includes weekend and holiday coverage.
Requirements
- M.D. or D.O. degree with current, active board certification in an ABMS- or AOA-recognized specialty.
- At least 5 years of post-residency clinical practice and direct patient care experience.
- Active, unrestricted Virginia medical license.
- Ability to obtain and maintain medical licenses in Maryland, New Jersey, New York, and Pennsylvania.
Nice To Haves
- Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics.
- Prior utilization management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity.
- Medicaid and managed care experience.
- Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation.
- Experience using electronic health records and other clinical documentation systems.
Responsibilities
- Conduct utilization management and medical necessity reviews.
- Make prior authorization and precertification determinations.
- Perform concurrent reviews for inpatient and outpatient services.
- Review acute and post-acute care.
- Conduct peer-to-peer consultations with treating providers.
- Perform pharmacy reviews and first-level appeal determinations.
- Collaborate with multidisciplinary clinical and operational teams.
- Participate in a rotating on-call schedule that includes weekend and holiday coverage.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources to support physical, emotional, and financial well-being, based on eligibility
- CVS Health bonus, commission, or short-term incentive program eligibility
- Award target in the company’s equity award program
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Ph.D. or professional degree
