Job Description: Lead utilization management, including predetermination and UM reviews Apply clinical expertise to support accurate, consistent decisions Participate in developing, implementing, and evaluating clinical/medical programs Expand Aetna's medical management programs across the continuum of care Support Medical Management staff in delivering timely, consistent responses to members and providers Oversee utilization review and quality assurance activities Direct case management efforts Provide clinical expertise and business direction for medical management programs Serve as lead clinical and business liaison to network providers and facilities Represent Aetna One Advocate in external-facing presentations and plan sponsor meetings, approximately 15% of the time Provide clinical oversight for medical policy implementation Requirements: Active, unrestricted MD required M.D. or D.O. Board Certification in an ABMS recognized specialty Post-graduate direct patient care experience Board certification/eligibility in Neurosurgery, Orthopedic Surgery, General Surgery, or Physical Medicine & Rehabilitation (PM&R) strongly preferred Comfort and experience presenting to external audiences Strong public speaking and stakeholder communication skills Collaborative mindset and comfort working in a close, fast-moving clinical team No prior utilization management or managed care experience required; full training provided Benefits: CVS Health bonus, commission or short-term incentive program Equity award program Medical coverage Dental coverage Vision coverage Paid time off Retirement savings options Wellness programs Other resources supporting physical, emotional, and financial well-being
