Job Description
Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources.
**This is a remote based (work from home) role and can be based anywhere in the US.**
Aetna Medicaid is looking for a Medical Director to support the Texas STAR Kids plan. The Medical Director will be based primarily at Aetna Better Health of Texas as part of a centralized team that supports Kansas, Texas, and Maryland Medical Management staff, ensuring timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request.
Aetna operates Medicaid managed care plans in sixteen states: Arizona, California, Florida, Illinois, Kansas, Kentucky, Louisiana, Maryland, Michigan, New Jersey, New York, Ohio, Pennsylvania, Texas, Virginia and West Virginia.
The Medical Director is a work-at-home position supporting the Aetna Medicaid line of business in these sixteen states, offering a variety of physical and behavioral health programs and services to its membership.
Fundamental Components:
- Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials.
- Appeals – The medical director will perform appeals in their “base plan” and in other plans based on “same or similar specialty” needs.
- Pharmacy coverage – The medical director will perform pharmacy reviews.
- The medical director will participate in and be able to lead daily rounds.
The medical director will participate in the rotating weekend on-call schedule for the region.
Required Qualifications
- Minimum 3 years of clinical practice experience in the health care delivery field.
- Board certification in pediatrics or med/peds and an active Texas license without encumbrances are required.
- Multiple state licensure is a plus.
- The Medical Director will need to obtain an administrative license in Kansas.
COVID Requirements
COVID-19 Vaccination Requirement
CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.
- If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 10 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 45 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
- If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 10 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.
Preferred Qualifications
- Experience with managed care
- Utilization review experience.
Education
The minimum level of education required for candidates in this position is MD or DO certification.
Business Overview
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.