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Medical Director - Allentown, PA #7249753

Company: Aetna

Date: 01/24/2020

Category: Healthcare Services

City: Allentown, PA

Req ID: 67917BR


Job Description


Provide oversight for medical policy implementation. Participate in the development, implementation, and evaluation of clinical/medical programs.


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.


Functional Skills:


Medical Management - Medical Management - Clinical claim review, Medical Management - Medical Management - Complaints, Grievance & Appeals, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Precertification


Technology Experience:


Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word


Required Skills:


Benefits Management - Encouraging Wellness and Prevention, Benefits Management - Interacting with Medical Professionals, Benefits Management - Supporting Medical Practice, Benefits Management - Understanding Clinical Impacts, General Business - Applying Reasoned Judgment, General Business - Communicating for Impact, General Business - Consulting for Solutions, General Business - Demonstrating Business and Industry Acumen, General Business - Maximizing Work Practices, Service - Demonstrating Service Discipline, Service - Handling Service Challenges, Service - Improving Constituent-Focused Processes


Desired Skills:


Leadership - Creating a World Class Workforce, Leadership - Creating Accountability, Leadership - Developing and Executing Strategy, Leadership - Driving a Culture of Compliance, Leadership - Driving Change


Benefit Eligibility


Benefit eligibility may vary by 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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