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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive expertise in medical policy implementation, clinical program development, and utilization review within the healthcare delivery system. Holds an active medical license and board certification, providing clinical and coding expertise to support medical management programs.
Highest-signal resume keywords
Medical Policy ImplementationUtilization ReviewClinical Program DevelopmentActive 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 ExpertiseCoding ExpertiseReimbursement ExpertiseCase ManagementQuality Assurance
Soft Skills
LeadershipCommunicationCollaboration
Certifications & Qualifications
M.D.D.O.Board Certification in ABMS or AOA Specialty
Industry Keywords
Health Care Delivery SystemMedical Management ProgramsHealth PlanPhysician AdvisorDirect Patient Care
About the role
Key responsibilities & impact- Provide oversight for medical policy implementation
- Participate in the development, implementation, and evaluation of clinical / 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, First Level Appeals, Special Projects, and Committee participation as needed
- Provide clinical, coding, and reimbursement expertise
- Direct case management when necessary
- Provide clinical expertise and business direction in support of medical management programs
- Act as lead business and clinical liaison to network providers and facilities
Requirements
What you’ll need- Five (5) or more years of experience in Health Care Delivery System, e.g., Clinical Practice and Health Care Industry
- Active and current medical license without encumbrances in one of the Midland States (IL, MO, MN, WI)
- M.D. or D.O.
- Active and Current Board Certification in an ABMS or AOA recognized specialty
- Post-graduate direct patient care experience
- Previous UM experience with a Health Plan / Payor / Physician Advisor in a Healthcare system (preferred)
- Board Certification in Internal Medicine, Family Medicine, Emergency Medicine, Med / Peds / General Surgery (preferred)
Benefits
Comp & perks- CVS Health bonus, commission or short-term incentive program
- Award target in the company’s 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