Medical Director (Medical Policy & Operations)
Core
Provide clinical expertise to promote high-quality, constituent-focused medical care with a focus on clinical and payment policy, including transactional reviews for appeals, claim reviews, and predetermination of covered benefits.
Role type
Senior IC Medical Director (Medical Policy & Operations)
Builds
Clinical and payment policies for Commercial and Medicare environments
Domain
Health Insurance / Medical Policy
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical practice experience, Health care industry experience, Medical coding (HCPCS/CPT), Clinical policy expertise, Reimbursement expertise, Data analysis, Team leadership
Preferred skills
Health plan/payor experience, Internal consulting, Subject matter expertise in clinical and payment policy
Technologies
HCPCS, CPT
Responsibilities
Conduct transactional reviews in support of the appeal process, Perform clinical claim review process, Determine predetermination of covered benefits, Apply clinical coding and reimbursement expertise to align with Aetna policies, Use data analysis to identify opportunities for quality improvement, Lead diverse teams of health delivery professionals
Seniority
Senior, hands-on IC