Medical Director - Medical Policy & Operations
About the position Responsibilities • Support the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. • Participate on work groups as a clinical subject matter expert to identify and promote opportunities to improve the quality and efficiency of health care services. • Apply clinical coding and reimbursement expertise to ensure alignment and correct application of Aetna policies and practices to service and payment requests. • Proactively use data analysis to identify opportunities for quality improvement and positively influence the effective delivery of quality care services. • Be a subject matter expert and internal consultant and payment policy contributor. • Demonstrate 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. • Work collaboratively with the functional areas. Requirements • Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. • Active and current state medical license without encumbrances. • M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience. Nice-to-haves • Health plan/payor experience. • Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems. • Strong communication skills both written and verbal. Benefits • Affordable medical plan options. • 401(k) plan (including matching company contributions). • Employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. Apply tot his job