Medical Director Aetna Duals Center of Excellence
CVS Health•Oklahoma City, IL
•$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.
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.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Ph.D. or professional degree
