Description
We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.
As the Behavioral Health SIU Medical Director, you will apply psychiatric expertise to reviews of medical records, CPT codes, and HCPCS codes involving suspected fraud, waste, abuse, care of limited clinical benefit, or potentially harmful practice variation.
Responsibilities:
- Serve as the psychiatric advisor to SIU investigators and leaders, reviewing medical records, coding, and claims involving suspected fraud, waste, abuse, or harmful practice variation.
- Proactively surface new investigative opportunities while providing clinical support for active investigations and related legal actions.
- Use clinical expertise, population-level data, advanced analytics, AI, and practice-pattern insights to identify trends, prioritize investigations, and scale clinical impact.
- Lead cross-functional investigations with clinical, claims, legal, compliance, network, quality, data, and operational partners to address root causes and implement sustainable solutions.
- Assess member risk and care variation, document clear findings, and translate complex evidence into recommendations for leaders, customers, and other stakeholders.
- Prepare well-supported cases for clinical and legal review and, when required and approved by Legal, provide testimony in civil or criminal proceedings.
- Conduct required peer-to-peer reviews and model Aetna’s Employee Competencies in all interactions.
Requirements:
- Five or more years of experience in a health care delivery setting, including clinical practice.
- Board certification in psychiatry; board eligibility alone is not sufficient.
- Knowledge of policies and procedures governing payment of health care claims.
Preferred Qualifications:
- At least two years of health care industry experience, including knowledge of CPT and HCPCS coding guidelines.
- Experience applying psychiatric expertise to medical record review and claim-payment determinations under company, state, federal, and industry standards.
- Experience providing psychiatric guidance in the development of business analytics.
- Familiarity with advanced analytics, artificial intelligence, health care technology, population health data, and physician practice-pattern analysis.
- Experience partnering with clinical, investigative, legal, compliance, data science, and operational teams to evaluate complex utilization or claims patterns and drive results.
Benefits: This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Pay Range: $174,070.00 - $374,920.00