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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 oversight in medical policy implementation, with a strong focus on utilization review, quality assurance, and member care across the continuum. Holds an active medical license and board certification, ensuring compliance and leadership in healthcare delivery.
Highest-signal resume keywords
Medical Policy ImplementationUtilization ReviewClinical ExpertiseBoard CertificationHealth Care Delivery System 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 PracticeUtilization ManagementPrior AuthorizationPre CertificationConcurrent ReviewsPeer to Peer CallsFirst Level AppealsCoding ExpertiseReimbursement ExpertiseCase Management
Soft Skills
LeadershipCommunicationCollaborationProblem-SolvingInterpersonal Skills
Certifications & Qualifications
Active Medical LicenseBoard Certification in ABMS or AOA Specialty
Industry Keywords
Health Care Delivery SystemHealth PlanPhysician AdvisorClinical ProgramsQuality Assurance
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
- Perform predetermination reviews and review claim determinations
- Conduct 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 through participation in clinical team activities
- 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, such as Clinical Practice and 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
- Ideal candidates reside in IL, MO, MN, or WI
- 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, or 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