Medical Director (Aetna Medicaid KY SKY)

Job Description
Summary:

The Medical Director shall be a physician licensed and in good standing to practice in the Commonwealth of Kentucky. The Medical Director shall be a pediatrician certified by the American Board of Pediatrics. The Medical Director shall be actively involved in all major health programs of the Kentucky SKY Contractor. This position provides oversight to clinical directors, including those employed by subcontractors, for all responsibilities of the Kentucky SKY Contract. The Medical Director shall also be responsible for treatment policies, protocols, quality improvement activities, population health management activities, and utilization management decisions related to the Kentucky SKY program and devote sufficient time to ensure timely clinical decisions. The Medical Director shall also be available for after-hours consultation, if needed.

This position develops, implements, supports, and promotes Health Services strategies, tactics, policies, and programs that drive the delivery of quality healthcare to establish competitive business advantage for Aetna. Health Services strategies, policies, and programs are comprised of utilization management, quality management, network management and clinical coverage and policies.
Provides oversight for medical policy implementation. Participates in the development, implementation, and evaluation of clinical/medical programs. 

This position requires the ability to travel 15% of the time; use of a personal vehicle when traveling. Must have active and valid driver's license, reliable transportation and vehicle insurance. Candidate must reside in commutable proximity to the Louisville office location, preferably in Louisville/Lexington areas or surrounding NKY area. Travel to the Louisville office and other in-state locations, such as Frankfort for state meetings, is required. Ability to travel/attend business meetings, possibly with 24 hour notice, is required. Out of state residents who can obtain a KY license and be in Frankfort KY for state meetings when necessary with short notice (24 hours) would be considered. Work at Home is a viable option.     




 

Fundamental Components
Responsibilities:

Conducts pre-certification review and determination (BH, PH, RX).

Conducts peer-to-peer reviews.

Conducts health plan rounds (IDT/UM support).

Provides appeals support with CMOs.

Conducts clinical claims reviews.

Provides oversight for medical policy implementation. Participates in the development, implementation and evaluation of clinical/medical programs.

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.

Oversees 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.

Background Experience
Background / Experience:

Active and current state medical license without encumbrances.

M.D. or D.O., Board Certification in Pediatrics or Internal Medicine / Pediatrics including postgraduate direct patient care experience.

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

Computer literacy and demonstrated proficiency is required in order to navigate through internal/external computer systems, and

MS Office Suite applications, including Word and Excel.

Additional Job Information
At Aetna Better Health of Kentucky, we reach beyond ensuring access to quality health care by focusing on resilient healing for children and their families. Our vision is to construct local, regional, and state-level coalitions to create a shared, in-common vision of health promoting and resiliency building approaches, to engage and support children to have membership in a family and community, while services and permanency planning are occurring.   By keeping families safely together, children in Kentucky SKY will experience less trauma, which leads to better outcomes.  To accomplish this, we are looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to supporting children, young people, parents, and other important partners involved with child protection systems. We value diversity and are dedicated to helping you achieve your career goals.

Education
MD

Percent of Travel Required
10 - 25%