Medical Director (Medical Policy & Operations)

Aetna, a CVS Health company has an outstanding opportunity for a Medical Director. This is a remote Work at Home position and can be located anywhere in the United States. In this role as Medical Director MPO (Medical Policy & Operations) you will be 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 on clinical and payment policy. This Medical Director provides subject matter expertise 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. The Primary Responsibilities of the Medical Director include support of the appeal process, clinical claim review process, pre-certification, and predetermination of covered benefits in the Commercial and Medicare environment. 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 ensure 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 subject matter expert and internal consultant and payment policy contributor subject matter expertise and internal consultant. Demonstrate 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. Work Collaboratively with the functional areas. Required Qualifications: Five (5) or more years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Active and current state medical license without encumbrances. M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience. Preferred Qualifications: Health plan/payor experience. Foundational baseline skills in Medicine, Health Policy, Coding: HCPCS / CPT, Clinical Policy, Reimbursement and Health Care Systems. Strong communication skills both written and verbal. Education: M.D. or D.O., Board Certification in an ABMS recognized specialty including post-graduate direct patient care experience.