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We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Aetna, a CVS Health Company, a Fortune 6 company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.
Job Responsibility:
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
Leads all aspects of 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, using multiple computer based applications
Requirements:
2 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 a Orthopedic Spine OR Neurosurgery, including post-graduate direct patient care experience specifically
Nice to have:
Previous healthcare insurance experience
What we offer:
Affordable medical plan options
401(k) plan (including matching company contributions)
Employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching