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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates clinical expertise and oversight in medical policy implementation, with a focus on utilization review and quality assurance. Provides leadership in medical management programs and effective execution of clinical services.
Highest-signal resume keywords
M.D. Or D.O.Board Certification In An ABMS Or AOA Recognized SpecialtyPost-Graduate Direct Patient Care ExperienceActive And Current State Medical LicenseUtilization Management Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Program DevelopmentUtilization ReviewQuality AssuranceCase ManagementPrior AuthorizationPre CertificationConcurrent ReviewsPeer To Peer CallsFirst Level AppealsCommittee Participation
Soft Skills
Effective CommunicationLeadershipCollaboration
Certifications & Qualifications
Board Certification
Industry Keywords
Medical ManagementHealth PlanPayorClinical ExpertiseMember Needs
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 with timely and consistent responses to members and providers
- Oversee utilization review / quality assurance
- Conduct predetermination reviews, including Prior Authorization, Pre Certification, Concurrent Reviews, Peer to Peer Calls, First Level Appeals, Special Projects, and Committee participation
- Provide clinical expertise and direct case management when necessary
- Provide clinical expertise and business direction through participation in clinical team activities
- Act as lead business and clinical liaison to network providers and facilities
- Support effective execution of medical services programs by clinical teams
Requirements
What you’ll need- M.D. or D.O.
- Board Certification in an ABMS or AOA recognized specialty
- Post-graduate direct patient care experience
- Active and current state medical license
- Active and current state medical license in either PA/WV/DE state without encumbrances preferred
- Previous UM experience with a Health Plan/Payor preferred
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- CVS Health bonus, commission or short-term incentive program
- Award target in the company’s equity award program
- Comprehensive benefits package supporting physical, emotional, and financial well-being