Clinical Solutions MD

Aetna Inc. Baton Rouge , LA 70804

Posted 2 months ago

Job Description:

POSITION SUMMARY

Operating with a balance of internal and external-facing activities that support a shift to a higher-touch, patient-centric focus, the Medical Director will develop, implement, support, and promote population health strategies, tactics, policies, and programs that drive the delivery of high value healthcare to establish a sustainable competitive business advantage for Aetna. These strategies, policies, and programs are comprised of care management, utilization management, quality improvement, network management as well as clinical coverage protocol. The Medical Director will be provider facing and have fluency in data analytics.

This position supports our GLAM market (GA / LA / AL / MS) and can be a work at home position. Louisiana location is highly preferred!

Fundamental Components:

Ability to collaborate with all stakeholders, understanding the guidelines/basics (how to access) the requirements, opportunities to shape within the scope in the role as a Health plan medical director.

Analytics-Oriented Care:

Ability to analyze data (e.g., medical cost trends) and articulate trend and solutions.

Ability to manage complex cases and client relationships with plan sponsors.

Proactive Virtual and Physician Engagement:

Leveraging multi-channel platforms and digital technology to interface with internal and external customers in virtual and physical settings.

End to End Market Understanding:

Strong business acumen.

Understands and proficient articulating products, financial impacts and market demands.

Consultant and supplier of actionable information.

Expertise in market/state DOL regulations delivering HEDIS/STARS consultation.

Communications:

Both oral and written skills and comfort in presenting to varied groups.

Key Responsibilities:

Building and fostering relationships and partnering with the external community and providers in a pro-active approach to population health.

Using data analytics to inform and influence population health to drive behavior change and expand Aetna's medical management programs to address specific member conditions across the continuum of care.

Collaborating with the Medical Management staff both internally and externally ensuring timely and consistent responses to members and providers.

Providing clinical expertise and business direction in support of medical management programs through active collaboration and participation in clinical team activities.

Acting as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams.

Attend & engage in Sales presentation meetings when necessary providing the value prop/story behind the partnerships Executing predetermination reviews, reviews of claim determinations, providing clinical, coding, and reimbursement expertise.

Manage UM transactional work(front line reviews and appeals).

Building and inspiring a culture of continuous improvement for better quality of care.

Creating products that utilize patient engagement in a new and effective manner utilizing tools and analytics.

Overseeing utilization review/quality assurance directing case management.

Provide UM services based on business demands and shifting business needs

BACKGROUND/EXPERIENCE
2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

Previous Managed Care experience with a payer / insurance company preferred

EDUCATION

The highest level of education desired for candidates in this position is a MD or DO.

LICENSES AND CERTIFICATIONS

And Active Unrestricted State Medical License is required.

Active Board Certification in a recognized specialty is required

FUNCTIONAL EXPERIENCES

Functional

  • Medical Management/Medical Management

  • Administration/Management/1-3 Years

Functional

  • Medical Management/Medical Management

  • Concurrent Review/1-3 Years

Functional

  • Medical Management/Medical Management

  • Physician Relations/1-3 Years

Functional

  • Clinical / Medical/Direct patient care (hospital, private practice)/1-3 Years

Functional

  • Clinical / Medical/General Management/1-3 Years

TECHNOLOGY EXPERIENCES

Technical

  • Desktop Tools/Microsoft Word/1-3 Years/End User

Technical

  • Desktop Tools/Microsoft Outlook/1-3 Years/End User

Technical

  • Desktop Tools/Microsoft PowerPoint/1-3 Years/End User

Technical

  • Desktop Tools/TE Microsoft Excel/1-3 Years/End User

DESIRED SKILLS

Benefits Management/Maximizing Healthcare Quality/ADVANCED

Service/Providing Solutions to Constituent Needs/ADVANCED

ADDITIONAL JOB INFORMATION

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.


See if you are a match!

See how well your resume matches up to this job - upload your resume now.

Find your dream job anywhere
with the LiveCareer app.
Download the
LiveCareer app and find
your dream job anywhere
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Clinical Psychologist Telehealth

Home Care Options

Posted Yesterday

VIEW JOBS 11/20/2018 12:00:00 AM 2019-02-18T00:00 <span style="font-family: georgia,serif;">Physicians Home Care Organization – PHCO – is a parent company for multiple healthcare entities. The goals of the highly coordinated team of health professionals in each PHCO Clinic site are to improve members’ health and wellness, improve access to care, utilize telemedicine and technology to enhance the member and provider experience, and improve the satisfaction of members, providers, and staff.:</span> <ul> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Family Medical Clinic</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Weight Loss Clinic</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Allergy Clinic</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Physician & Nurse Practitioner House Calls</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">E-visits by Physician & Nurse Practitioners</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Occupational Medicine</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Behavioral Health & Counseling</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Personal Care Services</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Private Sitting Services</li> </ul> <strong>Licensed Clinical Psychologist </strong> <strong> -Telehealth </strong> <div>PHCO is launching a nationwide telehealth initiative to provide behavioral health services to those in need. <strong>We are looking for Psychologists who want to practice telehealth.</strong></div> <div>This position requires getting licensed in multiple states which PHCO will pay for.</div> <div>An increasing population of geriatric patients are finding themselves in rural areas, relying on local general practice physicians without specialized training in elderly mental health care, or needing to travel long distances to be assessed and appropriately treated. An increasing need of children and families also stand in need with lack of access to be assessed and appropriately treated. PHCO new Telehealth Initiative provides a crucial solution to this problem by virtually bringing our world-class clinicians to patients in need.</div> <ul> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">HIPAA secured video conferencing technology allows access patient and staff access to our clinical teams.</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Consistent scheduling assures that all patients who need to be “seen” will be.</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">An on-site clinical manager facilitates the virtual visit.</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">A PHCO team of psychiatry and psychology providers specializing in geriatric, children and family behavioral health care will provide the assessment, diagnostic, and treatment services.</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Telehealth offers improved resident/patient, facility, family outcomes as a result of the increased access to specialized care, as well as dramatically reduced costs.</li> </ul> <div><strong>We Offer: </strong></div> <ul> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Flexible working schedule</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Highly competitive compensation</li> <li style="margin: 0px; padding: 0px;" style="padding: 0; margin: 0;">Referral bonus program</li> </ul> Home Care Options Baton Rouge LA

Clinical Solutions MD

Aetna Inc.