Medical Director (Medical Policy Ops-DRG)
About The Position
Aetna, a CVS Health company, has an outstanding opportunity for a Medical Director. Ready to take your career to the next level with a Fortune 6 company? This is a remote Work at Home position and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be responsible for providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy. The Primary Responsibilities of this Medical Director role include transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Commercial and Medicare environments. Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential. This Medical Director may also provide subject matter expertise in clinical and payment policy to support clinical and business direction in these areas. In addition, be a subject matter expert in DRG reviews and ICD-10 code selection. Additional responsibilities may include: ◾Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services. ◾Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. ◾Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services. ◾ Be a subject matter expert, internal consultant and payment policy contributor. ◾Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company. ◾Work Collaboratively with the functional areas.
Requirements
- Five (5) 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 an ABMS recognized specialty including post-graduate direct patient care experience
Nice To Haves
- Health plan/payor experience
- Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems
- Experience with DRG reviews
- Strong communication skills both written and verbal
- Knowledge of Aetna clinical and coding policy
- Experience with appeals, claim review, reimbursement issues, and coding
- Willingness to learn
Responsibilities
- Transactional reviews in support of the appeal process
- Clinical claim review process
- Predetermination of covered benefits in the Commercial and Medicare environments
- Provide subject matter expertise in clinical and payment policy to support clinical and business direction
- Be a subject matter expert in DRG reviews and ICD-10 code selection
- Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services
- Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests
- Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services
- Be a subject matter expert, internal consultant and payment policy contributor
- Demonstrate the ability to work within and lead as necessary teams comprised of a diverse group of health delivery professionals in order to manage the business objectives of the company
- Work Collaboratively with the functional areas
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
Senior
Education Level
Ph.D. or professional degree
