✨ About The Role
- The Medical Director will oversee medical policy implementation and participate in the development and evaluation of clinical programs.
- This role involves expanding Aetna's medical management programs to address member needs across the continuum of care.
- The Medical Director will focus on utilization review and quality assurance, including predetermination reviews and claims determinations.
- Responsibilities include conducting prior authorization, pre-certification, concurrent reviews, and first-level appeals.
- The Medical Director will act as a liaison to network providers and facilities to support effective execution of medical services programs.
âš¡ Requirements
- The ideal candidate will have at least two years of experience in the healthcare delivery system, including clinical practice and the healthcare industry.
- A current and active state medical license without encumbrances is required for this position.
- Candidates should possess an M.D. or D.O. degree and board certification in an ABMS or AOA recognized specialty.
- Previous experience in utilization management with a health plan or payor is preferred.
- The successful candidate will have strong clinical, coding, and reimbursement expertise.