Job Description
About the position
The Medical Director-Appeals role at Elevance Health is a hybrid position focused on overseeing appeal reviews for physical health medical services. The primary responsibility is to ensure that members receive appropriate and cost-effective medical care. The role involves developing and implementing programs aimed at improving quality, cost, and outcomes, as well as providing clinical consultation and serving as a strategic advisor to enhance clinical operations. The Medical Director may also identify cost of care opportunities and serve as a resource for staff, including Medical Director Associates.
Responsibilities
Β Conduct appeal reviews for physical health medical services.
,
Β Support clinicians to ensure timely and consistent responses to members and providers.
,
Β Provide guidance for clinical operational aspects of a program.
,
Β Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
,
Β Serve as a resource and consultant to other areas of the company.
,
Β Represent the company to external entities and/or serve on internal and/or external committees.
,
Β Chair company committees as needed.
,
Β Interpret medical policies and clinical guidelines.
,
Β Develop and propose new medical policies based on changes in healthcare.
,
Β Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
,
Β Identify and develop opportunities for innovation to increase effectiveness and quality.
Requirements
Β MD or DO with Board certification approved by ABMS or AOA.
,
Β Active unrestricted medical license to practice medicine or a health profession.
,
Β Minimum of 10 years of clinical experience or equivalent education and experience.
,
Β For Health Solutions and Carelon organizations, minimum of 5 years of experience providing healthcare is required.
Nice-to-haves
Β Board certification in Internal or Family medicine strongly preferred.
,
Β Florida medical license or the ability to obtain once hired strongly preferred.
Benefits
Β Merit increases
,
Β Paid holidays
,
Β Paid Time Off
,
Β Incentive bonus programs
,
Β Medical, dental, and vision benefits
,
Β Short and long term disability benefits
,
Β 401(k) with matching
,
Β Stock purchase plan
,
Β Life insurance
,
Β Wellness programs
,
Β Financial education resources
Apply Now