Medical Director-Medicaid (ABH VA)
$174,070–$374,920 year
RemoteNew York, United States or New Jersey, United States
Job Summary
Conduct utilization management and medical necessity reviews, including prior authorization, precertification, concurrent review for inpatient and outpatient services, and acute/post-acute care assessments. Perform peer-to-peer consultations with treating providers and pharmacy reviews to determine first-level appeal outcomes. Partner with multidisciplinary clinical and operational teams to ensure timely, consistent, and clinically sound decisions for Medicaid members across the Northeast Region and other health plans. Participate in a rotating on-call schedule covering weekends and holidays. This full-time, fully remote position supports Aetna Better Health of Virginia and requires an M.D. or D.O. with active Virginia licensure and board certification.
Required Qualifications
- M.D. or D.O. degree
- Board Certification in an ABMS- or AOA-recognized specialty
- 5+ years of post-residency clinical practice
- direct patient care experience
- Active, unrestricted Virginia medical license
- Ability to obtain and maintain medical licenses in Maryland, New Jersey, New York and Pennsylvania
- M.D. or D.O.
- Board Certification in ABMS or AOA recognized specialty
- post-graduate direct patient care experience
Desired Qualifications
- Board certification in Family Medicine, Emergency Medicine, or Internal Medicine-Pediatrics
- Prior Utilization Management experience with a health plan, managed care organization, Independent Review Organization, or in a Physician Advisor capacity
- Medicaid and managed care experience
- Experience with medical necessity review, prior authorization, concurrent review, appeals, and peer-to-peer consultation
- Experience using electronic health records and other clinical documentation systems
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