Medical Director – Medical Policy & Operations

Job Description:

• providing clinical expertise to promote the delivery of high quality, constituent focused medical care with a focus on clinical and payment policy
• transactional reviews in support of the appeal process, clinical claim review process, and predetermination of covered benefits in the Medicare and commercial environments, with emphasis on Medicare clinical and payment policy
• 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, internal consultant and payment policy contributor
• 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

Benefits:

• medical, dental, and vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility

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