Medical Director Aetna Duals Center of Excellence
About The Position
The Aetna Duals Center of Excellence operates Duals Integrated Plans in Illinois, Michigan, Virginia, Florida, and New Jersey, offering physical and behavioral health programs and services. The Medical Director joins a centralized team supporting Medical Management staff with timely, consistent responses to members and providers concerning precertification, concurrent reviews, and appeals. This is a work-at-home position that can be based anywhere in the United States. The full-time schedule is Monday through Friday, working 8:00 AM–5:00 PM Eastern or Central time. The role also requires working one holiday and eight weekend days each year, approximately one weekend per quarter.
Requirements
- At least 3–5 years of clinical practice experience.
- More than two years of experience in managed care, including Medicare and/or Medicaid.
- MD or DO degree.
- Board certification in an ABMS- or AOA-recognized specialty.
- Active, current state medical license without encumbrances.
- Florida medical license or ability to obtain one.
Nice To Haves
- Experience with utilization management, preferably in Medicare and/or Medicaid.
- Multiple state medical licensure.
- Previous utilization management or claims determination experience with another health plan, payor, hospital system, or health system.
- Licensed in or willing to obtain a license in at least one state where Aetna has an Integrated Plan.
Responsibilities
- Perform concurrent and prior authorization reviews, including peer-to-peer coverage of denials.
- Perform appeals in assigned base plans and provide coverage across plans based on same or similar specialty needs.
- Perform pharmacy reviews.
- Participate in rounds and be able to lead them.
Benefits
- Medical, dental, and vision coverage.
- Paid time off.
- Retirement savings options.
- Wellness programs and other resources, based on eligibility.
- Eligibility for a CVS Health bonus, commission, or short-term incentive program.
- An award target in the company 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
