CVS Health

Medical Director (BB-E1E7B)

Found in: Neuvoo IL

Job Description
Position Summary:

Aetna Medicaid 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.

This position will primarily support the Aetna Better Health of Illinois Medicaid plan and would be part of the team, run daily rounds, build clinical programs, support educational outreach, developing relationships with the state regulator and community partners, and participate in continuous quality improvement.

The medical director’s duties include performing utilization management medical and pharmacy concurrent and prior authorization reviews, supporting service coordinators/care managers, appeals and quality of care case reviews, and rotating weekend coverage (one in five-six weekends).

In addition to Illinois Medicaid duties, the medical director will also be part of a regional team consisting of the Illinois, Michigan, and Pennsylvania Medicaid plans and support other health plans as needed.

Aetna operates Medicaid managed care plans in sixteen states: Arizona, California, Florida, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Pennsylvania, Texas, Virginia and West Virginia.

Primary Responsibilities:

Performing utilization management medical and pharmacy concurrent and prior authorization reviews.

Supporting service coordinators/care managers. Attending multi-disciplinary case rounds to ensure optimal care for our members according to their benefits.

Performing peer to peer calls, appeals and quality of care case reviews, and rotating weekend coverage (one in four-five weekends).

Required Qualifications
Experience / Licenses / Certifications:

Minimum 3-5 years of clinical practice experience in the health care delivery field.

Experience with managed care (Medicaid and Medicare preferred) utilization review is preferred.

An active medical license without encumbrances is required.

Multiple state licensure is a plus.

Board Certification in a ABMS recognized specialty is required, preferably in pediatrics or internal medicine / pediatrics

Preferred Qualifications
Previous Utilization Review Experience Preferred

Doctor of Medicine (DO or MD)

Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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