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Medical Director – Medicaid
CVS Health. Support Aetna Better Health of Louisiana and other health plans as needed .
About the role
Key responsibilities & impact- Support Aetna Better Health of Louisiana and other health plans as needed
- Partner with Medical Management staff to ensure timely, consistent, and clinically sound decisions for members and providers
- Perform Utilization Management and medical necessity reviews
- Make prior authorization and precertification determinations
- Conduct concurrent reviews for inpatient and outpatient services
- Perform acute and post-acute care reviews
- Conduct peer-to-peer consultations with treating providers
- Perform pharmacy reviews and first-level appeal determinations
- Collaborate with multidisciplinary clinical and operational teams
- Participate in a rotating on-call schedule including weekend and holiday coverage
Requirements
What you’ll need- Active, unrestricted Louisiana medical license
- Ability to be licensed in Florida and Kentucky
- M.D. or D.O. degree
- Current, active Board Certification in an ABMS- or AOA-recognized specialty
- 5+ years of post-residency clinical practice and direct patient care experience
- Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics
- Prior Utilization Management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity
- Medicaid and managed care experience
- Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation
- Experience using electronic health records and other clinical documentation systems
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