• Provides leadership of medical management activities • Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality, cost and outcomes. • Direct the utilization review process and oversee the quality of utilization determinations. • Ensure compliance with clinical goals through monitoring care management performance. • Responsible for overall medical policies of the unit to ensure the appropriate and most cost effective medical care is received, and for the day-to-day management of medical management staff. • Responsible for recommending changes and enhancements to current managed care, review guidelines, and clinical criteria based on extensive knowledge of health care delivery systems, utilization methods, reimbursement methods, and treatment protocols. • Develops, implements, and interprets medical policy including medical necessity criteria, clinical practice guidelines, and new technology assessments. • Leads clinical staff in the coordination of quality care. • Provides clinical expertise and business direction in support of medical management programs through participation in clinical team activities. • Acts as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams. • Responsibility for predetermination reviews. • Expands Aetna's medical management programs to address member needs across the continuum of care. • Responsibility for reviewing and handling cases when needed • Responsibility to be on call when needed.