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Aetna Medical Director (Medical Policy & Operations) in Detroit, Michigan

Req ID: 62698BR

Job Description

Position Description

The Medical Director (MD) for Medical Policy & Operations is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent focused medical care with a focus clinical and payment policy specifically in the area of oral maxillary facial surgery.

This Medical Director provides subject matter expertise in oral maxillary facial surgery to provide clinical support and business direction in these areas.

Knowledge of Aetna clinical and coding policy and experience with appeals, claim review, reimbursement issues, and coding is preferable, but a willingness to learn is essential.

Fundamental Components/Job Description:

Basic responsibilities of this Medical Director include support of the appeal process, clinical claim review process, precertification, and predetermination of covered benefits as it relates to oral maxillary facial surgery. Additionally, this Medical Director provides subject matter expertise in clinical and payment policy to provide clinical support and business direction in these areas.

In this role you will:

-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 insure 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 policy contributor Aetna Clinical Policy Bulletin (Clinical Policy)

-Function as subject matter expertise and internal consulting role Payment policy contributor, subject matter expertise and internal consulting role

-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

-Works collaboratively with other functional areas

Background/Experience desired:

Medical/Medical License (MD/DO/DDS) is required

Active Unrestricted Board certification in oral maxillary facial surgery is required 2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry

Foundational baseline skills in Health Policy, Epidemiology, Coding:

ADDITIONAL JOB INFORMATION:

Are you ready to join a company that is changing the face of health care across the nation? Aetna Better Health of Texas is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you ll join a team dedicated to improving the lives of Texas Medicaid members. Our vision incorporates community-based health care that works. We value diversity. Align your career goals with Aetna Better Health of Texas, and we will support you all the way.

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Fundamental Components included but are not limited to:

Expands Aetna's medical management programs to address member needs across the continuum of care Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Oversees utilization review/quality assurance, directing case management Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise

Qualifications Requirements and Preferences:

2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Active and current state medical license without encumbrancesM.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.

Licenses/Certifications:

Medical - Medical License (for all states)

Functional Skills:

Clinical / Medical - Clinical claim review & coding

Technology Experience:

Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel

Required Skills:

General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Turning Data into Information

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Healthcare

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.

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