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Aetna Medical Director (Medicare Appeals) in Seattle, Washington

Req ID: 66029BR

Job Description

Position Description:

The Medical Director will be part of a team working on Medicare Appeals. This is a Work At Home Position after initial training has been completed. Previous Experience reviewing Medicare Claims Highly Preferred.

In this position you will:

Direct daily work on part C appeals (both provider and member/non-participating providers) and part D appeals.

Provide direct support to appeal nurses and dedicated Medicare part D pharmacists.

Supervision and participation in the Second Look Review (SLR) process.

Provide direct support to the SLR nurses.

Provide after hours and weekend coverage on a rotational basis to support 24/7 appeals work.

IRE monitoring and tracking.

Utilization Management support.

Collaborative work with Medicare Quality and Compliance on an ongoing basis.

Develop subject matter expertise on Medicare policy for the enterprise.

Provide ongoing education regarding Medicare policy and appeals to the appeal nurses and territory Utilization Management staff.

Participate in ongoing ABX initiatives to improve appeals team efficiency and clinical consistency.

Background /Experience:

2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

Previous managed care experience with an insurer / payer highly preferred but not required

Education:

The highest level of education desired for candidates in this position is an MD or DO.

License and Certifications:

M.D. or D.O., Board Certification in a Aetna recognized specialty including post-graduate direct patient care experience.

Active and current state medical license without encumbrances

Additional Job Information:

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Aetna takes our candidate s data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Licenses/Certifications:

Medical - Medical License (for all states)

Functional Skills:

Medical Management - Medical Management - Complaints, Grievance & Appeals

Additional Job Information:

Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come. We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence. Together we will empower people to live healthier lives. Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities. We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit Eligibility

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Job Function: Healthcare

Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.

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