CVS Health Medical Director in New York, New York
The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsor, and regulatory agencies and participates in the strategic medical management for our plan sponsors. The Medical Director will partner with medical management to increase effectiveness of medical management programs and promote integration of other Aetna medical programs
The Medical Director is part of a team of Medical Directors supporting the New Jersey Market which consists of Commercial and Medicare members. New Jersey location Preferred but not Required.
Full or Part Time:
Percent of Travel Required:
0 - 10%
Posting Job Title:
Medical Director (New Jersey Market)
Potential Telework Position:
DE-Wimington, NJ-Alexandria, NJ-New Brunswick, NJ-Princeton, NJ-Ramsey, NY-New York, PA-Philadelphia
Primary Location (City, State):
Aetna is an Equal Opportunity, Affirmative Action Employer
Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.
Manage UM transactional work (front line reviews and appeals).
Build and inspire a culture of continuous improvement for better quality of care.
Oversee utilization review/quality assurance directing case management.
Provide UM services based on business demands and shifting business needs
Lead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits.
Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (e.g. telephonic rounds) in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management.
Provide clinical guidance in the oversight of our value based arrangements including but not limited to accountable care organizations and Medicare collaborations
Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.
Proactively use data analysis to identify opportunities for overall value improvement (including both financial as well as quality improvement), to positively influence the effective delivery of quality care.
Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.
Work collaboratively with other functional areas that interface with medical management within the National Account Care Management Solutions Team including provider relations, sales, benefits, healthcare delivery, national medical services, local network and sales teams and national accounts to achieve the business goals of the company.
Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.
Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved.
The highest level of education desired for candidates in this position is a MD or DO
LICENSES AND CERTIFICATIONS
Medical/Medical License (MD) or (DO) is required
An Active Unrestricted State Medical License is required
Active Board Certification in an Aetna recognized specialty is required
Internal Medicine / Family Medicine / Emergency Medicine preferred
Work at Home with NJ, NY and PA preferred though open to other areas
ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come. We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence. Together we will empower people to live healthier lives.
Benefit eligibility may vary by position.
Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Clinical Licensure Required:
Board Certified MD
- CVS Health Jobs