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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical policy implementation and clinical program development, with a strong focus on utilization review and quality assurance. Possesses extensive experience in direct patient care and medical management within a health plan environment.
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
Medical Policy ImplementationClinical Program DevelopmentUtilization ReviewQuality AssurancePredetermination ReviewsPrior AuthorizationPre-CertificationConcurrent ReviewsPeer-To-Peer CallsFirst-Level Appeals
Soft Skills
Clinical ExpertiseEffective CommunicationTeam CollaborationLeadership
Certifications & Qualifications
Board Certification
Industry Keywords
Medical Management ProgramsHealth PlanPayorCase ManagementNetwork ProvidersFacilities
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, including prior authorization, pre-certification, concurrent reviews, peer-to-peer calls, and first-level appeals
- Participate in special projects and committees as needed
- Provide clinical expertise and direct case management when necessary
- Support medical management programs through clinical team activities
- Serve 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, or DE without encumbrances preferred
- Previous UM experience with a Health Plan/Payor 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