Medical Director Aetna Duals Center of Excellence

Position Summary:

The Aetna Duals Center of Excellence (COE) operates Duals Integrated Plans and Medicare ISNP Plans in Ohio, Illinois, Michigan, Virginia, Pennsylvania, and New Jersey offering a variety of physical and behavioral health programs and services to its membership.

Aetna is looking for a Medical Director to be part of a centralized team that supports the Medical Management staff ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request. The Medical Director is a work-at-home position located anywhere in the US.

The Medical Director will work a full-time schedule Monday to Friday. The Medical Director can work from any state but will be required to work Eastern Standard Time or Central Standard time 8:00 AM - 5:00 PM. The Medical Director will also be expected to work 1 holiday and 8 weekend days (approximately 1 weekend per quarter) each year.

Fundamental Components:

• Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials. • Appeals – The medical director will perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs. • Pharmacy coverage – The medical director will perform pharmacy reviews. • The medical director will participate in and be able to lead rounds.

Required Qualifications:

• Minimum 3-5 years of clinical practice experience.
• Two (2) + years of experience in managed care (Medicare and/or Medicaid)
• Experience with managed care (Medicare and Medicaid) utilization review preferred
• MD or DO; Board certification in an ABMS or AOA recognized specialty is required
• Active and current state medical license without encumbrances is required. Multiple state licensure a plus.

Preferred Qualifications:

• Previous Experience in Utilization Management / Claims Determination with another Health Plan / Payor or Hospital System / Health System.
• Licensed in or willing to obtain license in at least one state where we have an Integrated plan.

Education MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine)