Medical Director

Responsibilities

• Provide oversight for medical policy implementation supporting Mercy Care (Aetna Medicaid Business in Arizona).
• Participate in the development, implementation, and evaluation of clinical and medical programs.
• Oversee utilization review and quality assurance, including predetermination reviews and claim determinations.
• Manage Prior Authorization, Pre-Certification, Concurrent Reviews, Peer-to-Peer calls, and all levels of appeals.
• Act as a lead clinical and business liaison to network providers and facilities.
• Provide clinical, coding, and reimbursement expertise and direct case management when necessary.
• Participate in a weekend, holiday, and on-call rotation.

Requirements

• M.D. or D.O. degree.
• Active and current medical license without encumbrances.
• Active Arizona (AZ) medical license without encumbrances.
• Board Certification in an ABMS or AOA recognized specialty.
• 2+ years of experience in a Health Care Delivery System (e.g., Clinical Practice or Health Care Industry).
• Willingness to travel up to 10% overnight.

Preferred Qualifications

• Previous Utilization Management (UM) experience with a Health Plan or Payor.
• Previous UM experience as a Physician Advisor in a Health or Hospital system.
• Board Certification in Internal Medicine, Family Medicine, or Emergency Medicine.

About the Company

Aetna, a CVS Health Company, is one of the oldest and largest national insurers. We believe that a better care system is more transparent and consumer-focused, recognizing physicians for their clinical quality and effective use of health care resources.