POSITION SUMMARY: The position is for a Medical Director in the Northeast Region (Work at Home) that will report directly to the Regional Medical Director of Medicare Clinical Operations. The MD will be support Medicare Clinical Operations, maintaining compliance with CMS/Medicare guidelines, through working collaboratively with our nurses and medical director, and cross functionally. Cross functional/key business partners include Medicare Compliance, Legal, Quality Management, Network, Sales, Medicare Operations. The MD is a critical medical and business leader and contact for external providers, plan sponsors, and regulatory agencies and participates in the strategic medical management of local market.
- This is a full time Work at Home opportunity. Position will support the Medicare Clinical Operations in the Northeast Region. Prefer candidates who currently reside in the Northeast.
EDUCATION and CERTIFICATION REQUIREMENTS:
- Leads the clinical staff in the coordination of quality, cost effective care on behalf of members utilizing their available Benefits.
- Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities in the execution of precertification, concurrent review/discharge planning, appeals, case management, disease management, and quality management.
- Partners with medical management leadership to increase effectiveness of medical management programs and to promote the integration of other Aetna medical programs.
- Provides clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care.
- Acts as the clinical lead to network providers and facilities to support effective execution of the medical services programs by the clinical teams.
- Participates in quality management activities at regional and market levels including those necessary to achieve NCQA and URAC accreditation.
- Proactively uses data analysis to identify opportunities for quality improvement and to positively influence the cost effective delivery of quality care.
- Mentors employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way.
- Works collaboratively with other functional areas that interface with medical management including provider relations, contracting, member services, sales, benefits and claims management, healthcare delivery, national medical services and business segments to achieve the business goals of the company.
- Leads clinical staff in assuring members' care is coordinated in a fashion that achieves the most value for the available benefits, and that a liaison is available to the members' caregiver for coordination of benefits.
- Acts as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general.
- Acts to engage providers and facilities in improving the cost and quality of care delivered to our members and assures that our shared business relationships are maintained and improved.
- Supports sales and marketing efforts including participation in key marketing activities and presentations.
- Participates in customer/consultant meetings as needed for new sales and retention opportunities.
- Partners with Account teams and customers to identify opportunities for improvement.
- Provides strategic medical management leadership.
- Demonstrates 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.
- Ensures rigorous, consistent and disciplined design and execution of medical management programs.
- Participates in workgroups, committees, project teams and strategic planning for the company in its mission to deliver cost-effective quality care.
- M.D. or D.O. from an accredited university.
- Completion of a Residency Training Program in a recognized primary care or specialist (medical or surgical) specialty.
- Active and current Board Certification in an American Board of Medical Specialties (ABMS) approved specialty is required; Internal Medicine, Family Practice or Emergency Medicine; will consider qualified applicants from other medical or surgical specialties.
- Board Certification in Geriatric Medicine (Internal Medicine), or Certificate of Added Qualifications in Geriatric Medicine preferred
- Must have an active and current medical license without encumbrances.
- 3-5 years experience in the health care delivery system e.g., clinical practice/direct patient care.
- Experience in Utilization Management (UM), Case Management (CM), and Disease Management (DM).
- Demonstrated appreciation of cultural diversity and sensitivity towards target populations.
- Sound clinical knowledge and recognized as a credible clinical resource.
- General knowledge of the health benefits business, clinical issues, trends and medical management, medical care delivery systems, utilization management, quality management, contracting, benefits interpretation, provider relations and customer service.
- Strong interpersonal and listening skills that bring out the best in medical management staff.
- Ability to work independently and adapt to team approach as necessary.
- Ability to build a high performing team by promoting a culture of energy and commitment, mentoring employees and supporting ongoing training and development of staff.
- Ability to successfully operate in a highly matrixed and changing environment.
- Effective and skilled public speaker and presenter.
- Strong oral and written skills.
- Ability to set and achieve goals.
- Ability to implement complex program and monitor implementation and modifications.
- Ability to manage multiple priorities and deadline in an expedient and decisive manner.
- Strong organizational skills.
- Comprehensive knowledge of Microsoft Office Suite.
- Leadership: Collaborating for Results and Driving a Culture of Compliance
- Benefits Management: Interacting with Medical Professionals, Maximizing Healthcare Quality, Encouraging Wellness and Prevention, Understanding Clinical Impacts and Supporting Medical Practice
- General Business/Demonstrating Business and Industry Acumen
Please note that benefit eligibility may vary by position. Click here to review the benefits associated with this position.
- Medical Management/Medical Management - Quality Management
- Medical Management/Medical Management - Case Management
Aetna does not permit the use of tobacco related products or drugs in the workplace.
Aetna - 2 years ago
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