Medical Director - Mercy Care
About The Position
Aetna, a CVS Health Company, is seeking a Medical Director to support Mercy Care, the Aetna Medicaid Business in Arizona. This is a remote-based position, ideally for candidates residing in Arizona with an unencumbered medical license. The role involves providing oversight for medical policy implementation, participating in the development, implementation, and evaluation of clinical/medical programs, and expanding medical management programs to address member needs. The Medical Director will support Medical Management staff, ensuring timely and consistent responses to members and providers. Key responsibilities include overseeing utilization review and quality assurance, handling predetermination reviews, and reviewing claim determinations. This encompasses Prior Authorization, Pre Certification, Concurrent Reviews, Peer to Peer Calls, All Level Appeals, and Special Projects/Committee participation. The role requires providing clinical, coding, and reimbursement expertise, directing case management, and acting as a lead business and clinical liaison to network providers and facilities. The position also includes participation in a weekend, holiday, and on-call rotation.
Requirements
- Two (2) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.
- Active and current medical license without encumbrances.
- M.D. or D.O.
- Active and Current Board Certification in an ABMS or AOA recognized specialty including post-graduate direct patient care experience.
- Overnight travel up to 10%
Nice To Haves
- Previous UM experience with a Health Plan / Payor.
- Previous UM experience as a Physician Advisor in a Health / Hospital system.
- Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine.
Responsibilities
- Provide oversight for medical policy implementation.
- Participate in the development, implementation, and evaluation of clinical/medical programs.
- Expand medical management programs to address member needs across the continuum of care.
- Support Medical Management staff ensuring timely and consistent responses to members and providers.
- Oversee utilization review and quality assurance.
- Responsible for predetermination reviews and review of claim determinations.
- Handle Prior Authorization / Pre Certification / Concurrent Reviews / Peer to Peer Calls / All Level Appeals / Special Projects and Committee participation.
- Provide clinical, coding, and reimbursement expertise.
- Direct case management when necessary.
- 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.
- Participate in a weekend, holiday and on-call rotation.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- CVS Health bonus, commission or short-term incentive program
- Equity award program
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Ph.D. or professional degree
