Medical Director Case Management

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Position Summary :

Aetna is as an industry leader in serving dual eligible populations by utilizing best-in-class operating and clinical models in both our Dually Eligible Special Needs Plan (DSNP) and our Medicare-Medicaid Plan (MMP) programs.

We collaborate with members, providers, and community organizations in pursuit of quality solutions that address the full continuum of our members’ health care and social determinant needs.

The Duals Care Management (CM) Medical Director will participate in designing, developing and deploying our Models of Care across all markets.

They will facilitate active communication between members, physicians and administration ensuring program design effectiveness.

Join us in this exciting opportunity as we grow and expand DSNP into new markets across the country.

Ability to work CST or EST Preferred.

Primary Duties and Responsibilities :

• Provides clinical oversight of the Dual Eligible Special Needs Plan (DSNP) and Medicare-Medicaid Plan (MMP) care management teams and the Interdisciplinary Care Team (ICT) processes by participating in the development of members’ Individual Care Plans (ICP) and assisting care management staff as they support of members’ physical, behavioral and socioeconomic needs.
• Partner closely with the Executive Director of Duals and other Duals Care Management leadership to collaborate across the enterprise and ensure that objectives are aligned, business strategies are delivered, and compliance and quality objectives are met.
• Consults with plan medical staff regarding adverse determinations, addresses issues related to network providers, performs medical chart reviews, and conducts physician peer-to-peer discussions as needed for the development of ICPs.
• Collaborates across the enterprise to ensure that the highest quality care is delivered to our members in an effective and efficient way.
• Contributes to strategies, tactics and programs for care management and community engagement for members, community partners and providers to create local strategies as needed.
• Assists in developing new and innovative health-related activities to meet the clinical mission, goals and philosophy of care for the health plan’s dual members.
• Collaborates with the Learning and Performance Team to develop clinical training for care management staff.
• Ensures timely execution of all deliverables in accordance with due dates and Federal / state regulatory requirements.
• Collaborates with department leadership and business analysts to interpret utilization data and proposes clinical programs and / or improvements to effectively manage trends.

Participate in UM activities as needed by the market including but not limited to UM case reviews, member and provider appeals

Participate in an on call schedule as needed

Travel to Provider, Member Meetings as indicated

Required Qualifications :

• Active and current medical license (MD or DO) without encumbrances
• Board Certification in Family Practice, Internal Medicine, or Geriatrics
• Post-graduate direct patient care experience
• Flexibility with work schedule to meet business needs
• 3-5 years of Managed Care experience; Medicare and Medicaid including LTSS highly preferred
• 3-5 year of Care Management experience
• Ability to work effectively in a highly matrixed organization / environment
• Ability to engage at all levels, including physicians, vendors, community partners, administrative leaders, clinical leaders and staff.
• Ability to be agile, manage multiple priorities, and adapt to change with enthusiasm
• Ability to work virtually with occasional travel for in person Member and Provider Meetings( 10%)

Education :

MD (Doctor of Medicine) or DO (Doctor of Osteopathic Medicine)

Pay Range

The typical pay range for this role is :

$174,070.00 - $374,900.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.

The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

This position also includes an award target in the company’s equity award program.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.

The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.

The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits.

CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners.

As for time off, Company employees enjoy Paid Time Off ( PTO ) or vacation pay, as well as paid holidays throughout the calendar year.

Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.