Senior Medical Director Medicaid

CVS Health•Carapichaima, CT

4d•$184,112 - $396,550

About The Position

Aetna, a CVS Health Company has an outstanding opportunity for a Senior Medical Director to lead the Northeast Medicaid region. Aetna operates Medicaid Managed Care Plans in multiple states: Arizona, Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Oklahoma, Pennsylvania, Texas, Virginia and West Virginia. The Senior Medical Director provides leadership of medical management activities in Aetna’s Northeast region (Maryland, New Jersey, New York, Pennsylvania, and Virginia). This person will lead a team of Medical Directors, collaborate with health plan chief medical officers and implement medical management programs/policies.

Requirements

Five (5) or more years of experience in clinical practice.
Five (5) or more years administrative experience in the health care industry or managed care.
M.D. or D.O., Active Board Certification in an ABMS or AOA recognized specialty, including post-graduate direct patient care experience.
Current and Active State Medical License without encumbrances.

Nice To Haves

Previous UM experience with a Health Plan or Health / Hospital System.
Previous Medicaid experience strongly preferred.
Previous experience managing a team.
Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts.

Responsibilities

Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes.
Direct the utilization review process and oversee the quality of utilization determinations.
Ensure compliance with clinical goals through monitoring care management performance.
Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff.
Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
Leads clinical staff in the coordination of quality care
Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities.
Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.
Responsibility for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
Expands Aetna's medical management programs to address member needs across the continuum of care.
Participates in Executive Director, Utilization Management led meetings as is appropriate.
Excellent communication skills; liaise with all stakeholders: clinicians, and medical directors, and providers.
Collaborative and strategic in identification of scorable action items (SAI) in Medicaid.
Other assigned projects and tasks.