Medical Director (Commercial / Medicare)

  • Aetna
  • $174,155.00 - 199,650.00 / Year *
  • 415 Old Tappan Rd, Westwood, NJ 07675
  • Full-Time



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Primary Location: New York, New YorkAdditional Locations: NJ-Atlantic County, NJ-Bergen County, NJ-Burlington County, NJ-Gloucester County, NJ-Hunterdon County, NY-New York Apply The Medical Director (MD) is responsible for providing clinical expertise and business direction in support of medical management programs to promote the delivery of high quality, constituent responsive medical care. The MD is a critical medical and business leader and contact for external providers, plan sponsor, and regulatory agencies and participates in the strategic medical management for our plan sponsors. The Medical Director will partner with medical management to increase effectiveness of medical management programs and promote integration of other Aetna medical programs The Medical Director is part of a team of Medical Directors supporting our NJ market with continued growth expected in 2019. Experience working with Medicare Populations preferred. Fundamental Components: Execute predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise. Manage UM transactional work (front line reviews and appeals). Build and inspire a culture of continuous improvement for better quality of care. Oversee utilization review/quality assurance directing case management. Provide UM services based on business demands and shifting business needs Lead the clinical staff in the coordination of quality care on behalf of members utilizing their available benefits. Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities (eg. telephonic rounds) in the execution of precertification, concurrent review/discharge planning, case management, disease management, appeals, pharmacy review and quality management. Provide clinical guidance in operating effective medical programs to promote member quality of care and in reviewing potential lapses in the quality of care. Proactively use data analysis to identify opportunities for overall value improvement (including both financial as well as quality improvement), to positively influence the effective delivery of quality care. Mentor employees and supports ongoing training and development of clinical staff and acts in a manner consistent with the Aetna Way. Act as critical medical leader for external providers, plan sponsors, regulatory & accrediting agencies, and community in general. Act to engage providers and facilities in improving the quality of care delivered to our members and assures that our shared business relationships are maintained and improved. EDUCATIONThe highest level of education desired for candidates in this position is a MD or DO LICENSES AND CERTIFICATIONSMedical/Medical License (MD) or (D0) is requiredMedical/Board Certified, National Board Of Medical Examiners is requiredPrimary Care and related specialties as well as Internal Medicine / Family Medicine / Geriatrics preferred Medical/DEA License is requiredAn Active Unrestricted State Medical License is required Active Board Certification in a recognized specialty is required FUNCTIONAL EXPERIENCESFunctional - Medical Management/Medical Management - Direct patient care/4-6 YearsFunctional - Medical Management/Medical Management - Administration/Management/1-3 YearsFunctional - Clinical / Medical/Direct patient care (hospital, private practice)/4-6 Years REQUIRED SKILLSBenefits Management/Interacting with Medical ProfessionalsLeadership/Driving a Culture of ComplianceDESIRED SKILLSBenefits Management/Supporting Medical PracticeLeadership/Collaborating for Results TELEWORK SPECIFICATIONSWork at Home with NJ location preferred ADDITIONAL JOB INFORMATIONAetna 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. 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 candidates' 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. Be sure to include your preferences below so you won??t miss out on openings in your preferred job category and location. At Aetna, we are pioneering a total approach to health and wellness and we need talented candidates like you to join our team. Become a member of our talent community to be the first to know about career initiatives that match your skills and interests as they become available, in addition to details on upcoming events, networking opportunities, and news about Aetna. Join Our Talent Community Sign up to receive information about job openings that are tailored to your skills and interests. Plus, get the latest career news from Aetna. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company (Aetna) and its affiliates.
Associated topics: administrative, administrative assistant, administrative coordinator, administrative support, assist, asso, front desk, operation, operations director, support


* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.