Medical Director Aetna Duals Center of Excellence

CVS Health•Oklahoma City, IL

3d•$174,070 - $374,920•Remote

About The Position

The Aetna Duals Center of Excellence (COE) operates Duals Integrated Plans and Medicare ISNP Plans in Ohio, Illinois, Michigan, Virginia, Pennsylvania, and New Jersey offering a variety of physical and behavioral health programs and services to its membership. Aetna is looking for a Medical Director to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request. The Medical Director is a work-at-home position located anywhere in the US. The Medical Director will work a full-time schedule Monday to Friday. The Medical Director can work from any state but will be required to work Eastern Standard Time or Central Standard time 8:00 AM - 5:00 PM. The Medical Director will also be expected to work 1 holiday and 8 weekend days (approximately 1 weekend per quarter) each year.

Requirements

Minimum 3-5 years of clinical practice experience.
Two (2) + years of experience in managed care (Medicare and/or Medicaid)
MD or DO; Board certification in an ABMS or AOA recognized specialty is required.
Active and current state medical license without encumbrances is required.

Nice To Haves

Experience with managed care (Medicare and Medicaid) utilization review preferred
Multiple state licensure a plus.
Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System.
Licensed in or willing to obtain license in at least one state where we have an Integrated plan.

Responsibilities

Perform concurrent and prior authorization reviews with peer to peer coverage of denials.
Perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs.
Perform pharmacy reviews.
Participate in and be able to lead rounds.