Executive Director - Medical Director (Medicaid)

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Position Summary:

Aetna, a CVS Health Company has an outstanding opportunity for an Executive Medical Director (Medicaid).

The Executive Medical Director provides leadership of medical management activities.

This person will lead a team of Senior Medical Directors and implement medical management programs/policies.

Responsibilities include but can change as business needs dictate:

• Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes.
• Direct the utilization review process and oversee the quality of utilization determinations.
• Ensure compliance with clinical goals through monitoring care management performance.
• Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff.
• Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols.
• Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments.
• Leads clinical staff in the coordination of quality care. 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.
• Responsibility for predetermination reviews.
• Expands Aetna's medical management programs to address member needs across the continuum of care.
• Responsibility for reviewing and handling cases when needed
• Responsibility to be on call when needed.

Required Qualifications:

Strong clinical background with 5+ years of clinical experience in care delivery

Clinical experience in managed care environment (minimum of 5 years)

Experience in Utilization Management review and state regulations

Comfortable finding process improvement areas and leading change

Ability to identify opportunities to drive process improvements, to lead the change, and ensure the execution

Experience managing Medical Directors

Demonstrated knowledge and skills making data driven decisions

Ability to effectively manage multiple priorities and meet deadlines

Effective written and oral communication skills with all levels

Eloquence and finesse when communicating and ability to navigating to diffuse

Strong strategic thinking and planning

Five (5) or more years of experience in clinical practice.

Five (5) or more years administrative experience in the health care industry or managed care.

M.D. or D.O., Active Board Certification in an ABMS or AOA recognized specialty; including post-graduate direct patient care experience.

Current and Active State Medical License without encumbrances.

Preferred Qualifications:

Previous UM experience with a Health Plan or Health / Hospital System.

Previous Medicaid experience and in the MedCompass, QXNT, CAS and DAG platforms.

Previous experience with CMS and / or MCG guidelines as well as state specific Medicaid contracts.

Previous experience with NCQA accreditation

Education:

M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience.

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.  This position also includes an award target in the company’s equity award program. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.