Medical Director-Medicaid (ABH-LA)
Core
Lead clinical decision-making for Medicaid members across multiple states, focusing on utilization management, medical necessity reviews, and peer-to-peer consultations.
Role type
Senior Medical Director (Utilization Management)
Builds
Clinically sound utilization management decisions for Aetna Better Health of Louisiana and other state plans
Domain
US Healthcare / Medicaid Managed Care
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Utilization management, medical necessity review, prior authorization, concurrent review, peer-to-peer consultation, pharmacy review, first-level appeal determination, multidisciplinary team collaboration
Preferred skills
Family Medicine/Emergency Medicine/Internal Medicine-Pediatrics board certification, prior Utilization Management experience with health plans or IROs, Medicaid managed care experience, electronic health records proficiency
Technologies
Electronic health records, clinical documentation systems
Responsibilities
Conduct utilization management and medical necessity reviews; determine prior authorization and precertification; perform concurrent reviews for inpatient and outpatient services; conduct acute and post-acute care reviews; engage in peer-to-peer consultations with treating providers; review pharmacy claims and determine first-level appeals; collaborate with multidisciplinary clinical and operational teams; participate in rotating on-call schedule
Seniority
Senior, hands-on IC with leadership responsibilities