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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive clinical expertise and leadership in medical management programs, ensuring effective implementation and evaluation of clinical initiatives while providing oversight for utilization review and quality assurance processes.
Highest-signal resume keywords
Medical Policy ImplementationUtilization ManagementClinical ExpertiseActive Medical LicenseBoard Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Prior AuthorizationPre-CertificationConcurrent ReviewsPeer-To-Peer CallsFirst-Level AppealsClinical Program DevelopmentQuality AssuranceCase ManagementCoding ExpertiseReimbursement Expertise
Soft Skills
LeadershipCommunicationCollaborationProblem-SolvingInterpersonal Skills
Certifications & Qualifications
M.D.D.O.Board Certification in ABMS or AOA Specialty
Industry Keywords
Health Care Delivery SystemClinical PracticeHealth PlanPhysician AdvisorInternal MedicineFamily MedicineEmergency MedicineMed/PedsGeneral Surgery
About the role
Key responsibilities & impact- Provide oversight for medical policy implementation
- Participate in the development, implementation, and evaluation of clinical and medical programs
- Expand Aetna's medical management programs to address member needs across the continuum of care
- Support Medical Management staff in providing timely and consistent responses to members and providers
- Oversee utilization review and quality assurance
- Conduct predetermination reviews and review claim determinations
- Perform prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, and first-level appeals
- Participate in special projects and committees as needed
- Provide clinical, coding, and reimbursement expertise
- Direct case management when necessary
- Provide clinical expertise and business direction for medical management programs through clinical team activities
- Serve as lead business and clinical liaison to network providers and facilities
Requirements
What you’ll need- Five (5) or more years of experience in a health care delivery system, such as clinical practice and the health care industry
- Active and current medical license without encumbrances
- M.D. or D.O.
- Active and current board certification in an ABMS- or AOA-recognized specialty
- Post-graduate direct patient care experience
- Preferred: Previous utilization management experience with a health plan/payor or as a physician advisor in a healthcare system
- Preferred: Board certification in Internal Medicine, Family Medicine, Emergency Medicine, Med/Peds, or General Surgery
Benefits
Comp & perks- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Equity award program
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being