• Ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal requests. • Responsible for Utilization Management, including prior authorization and precertification as well as concurrent review. • Focus on inpatient or outpatient, acute and post-acute cases as well as peer to peer calls and first level appeals. • Participate in a rotating on call schedule to provide weekend and holiday coverage.

• Serve as the liaison between data analytics/reporting teams and the clinical leadership team • Identify trends in population health while providing a clinical perspective to support clinical solutions aimed at improving patient care • Leverage existing data and reporting sources as well as develop new analytics to support health plan senior leadership • Identify, develop, implement, and evaluate the effectiveness of strategic initiatives, trends, policies, and programs • Analyze policy/procedure/workflows on case management and utilization management for care redesign • Analyze Total Cost of Care, Stars, Risk Adjustment, etc. data for opportunities and propose Strategic Action Items and other initiatives to improve outcomes • Work collaboratively with various departments to improve Medicare business operations and clinical program execution • Develop and improve Medicare reporting, such as in Tableau • Lead and implement informatics communication efforts • Maintain strong collaborative relationships with care management teams • Actively participate in meetings and communications at various levels

• Utilization management – The medical director will perform concurrent and prior authorization reviews with peer to peer coverage of denials. • Appeals – The medical director will perform appeals in their “base plans” and may round robin based on “same or similar specialty” needs. • Pharmacy coverage – The medical director will perform pharmacy reviews. • The medical director will participate in and be able to lead rounds.

• Provide oversight for medical policy implementation as part of a team dedicated to the Federal Employee Health Benefits Program (FEHBP) • Participate in the development, implementation, and evaluation of clinical/medical programs • Expand Aetna's medical management programs to address member needs across the continuum of care • Support the Medical Management staff ensuring timely and consistent responses to members and providers • Oversee utilization review, quality assurance, case management, disease management, benefit planning, and fraud investigation • Provide clinical expertise and business direction in support of medical and pharmacy management programs • Act as a lead business and clinical liaison to network providers and facilities, plan sponsors, and related vendors • Support the effective execution of medical services programs by the clinical teams • Responsible for precertification reviews, appeals, and reviews of claim determinations