Req ID: 59902BR Job Description Provide oversight for medical policy implementation. Participate in the development, implementation, and evaluation of clinical/medical programs. Fundamental Components included but are not limited to: Expands Aetna's medical management programs to address member needs across the continuum of care Supports the Medical Management staff ensuring timely and consistent responses to members and providers. Oversees utilization review/quality assurance, directing case management Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise Qualifications Requirements and Preferences: 2-3 years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry. Active and current state medical license without encumbrances M.D. or D.O., Board Certification in a recognized specialty including post-graduate direct patient care experience. Licenses/Certifications: Medical - Medical License (for all states) Functional Skills: Clinical / Medical - Direct patient care (hospital, private practice), Clinical / Medical - General Management, Medical Management - Medical Management - Administration/Management, Medical Management - Medical Management - Concurrent Review, Medical Management - Medical Management - Physician Relations Technology Experience: Desktop Tool - Microsoft Outlook, Desktop Tool - Microsoft Word Required Skills: Benefits Management - Maximizing Healthcare Quality, Service - Providing Solutions to Constituent Needs Benefit Eligibility Benefit eligibility may vary by position. Click here to review the benefits associated with this position. Job Function: Health Care 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.