Medical Director - SWAT

CVS Health•Work At Home-Connecticut, CT

1d•$174,070 - $374,920•Remote

About The Position

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. This is a fully remote, work from home role. In the Medical Director role you will provide oversight for medical policy implementation. You'll participate in the development, implementation, and evaluation of clinical/medical programs and expand Aetna's medical management programs to address member needs across the continuum of care. You will support the Medical Management staff ensuring timely and consistent responses to members and providers. In addition you will oversee utilization review/quality assurance, directing case management In this role you'll provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities and 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. You'll be responsible for predetermination reviews ad reviews of claim determinations, providing 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 a recognized specialty including post-graduate direct patient care experience.

Nice To Haves

Health plan/payor experience.
Electronic medical systems/record experience
Managed Care experience

Responsibilities

Provide oversight for medical policy implementation.
Participate in the development, implementation, and evaluation of clinical/medical programs.
Expand Aetna's medical management programs to address member needs across the continuum of care.
Support the Medical Management staff ensuring timely and consistent responses to members and providers.
Oversee 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.