Medical Director Aetna Duals Center of Excellence
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary: 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. Fundamental Components: • Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials. • Appeals – The medical director will perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs. • Pharmacy coverage – The medical director will perform pharmacy reviews. • The medical director will participate in and be able to lead rounds.
Requirements
- Minimum 3-5 years of clinical practice experience.
- Two (2) + years of experience in managed care (Medicare and/or Medicaid)
- Experience with managed care (Medicare and Medicaid) utilization review preferred
- MD or DO
- Board certification in an ABMS or AOA recognized specialty is required.
- Active and current state medical license without encumbrances is required.
- Multiple state licensure a plus.
Nice To Haves
- 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
- Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials.
- Appeals – The medical director will perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs.
- Pharmacy coverage – The medical director will perform pharmacy reviews.
- The medical director will participate in and be able to lead rounds.
Benefits
- Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
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What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
Ph.D. or professional degree
