✨ About The Role
- The Medical Director will provide clinical expertise and business direction to support medical management programs focused on high-quality, constituent-focused medical care.
- Responsibilities include supporting the appeal process, clinical claim review, pre-certification, and predetermination of covered benefits in both Commercial and Medicare environments.
- The role requires participation in work groups as a clinical subject matter expert to identify and promote opportunities for improving healthcare service quality and efficiency.
- The Medical Director will apply clinical coding and reimbursement expertise to ensure alignment with Aetna policies and practices.
- Proactive data analysis will be utilized to identify quality improvement opportunities and influence the effective delivery of care services.
âš¡ Requirements
- The ideal candidate will have at least five years of experience in the healthcare delivery system, demonstrating a strong understanding of clinical practice and the healthcare industry.
- A current and active state medical license is essential, ensuring the candidate is qualified to provide medical expertise.
- Candidates should possess an M.D. or D.O. degree, with board certification in an ABMS recognized specialty and relevant post-graduate direct patient care experience.
- Strong communication skills, both written and verbal, are crucial for effectively collaborating with diverse health delivery professionals.
- Experience in health plan or payor environments, particularly with DRG reviews, will be highly beneficial for this role.