Medical Director-Appeals (Primary Care-IM or FM)

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
• Conduct appeal reviews for physical health medical services.
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• Support clinicians to ensure timely and consistent responses to members and providers.
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• Provide guidance for clinical operational aspects of a program.
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• Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
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• Serve as a resource and consultant to other areas of the company.
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• Represent the company to external entities and/or serve on internal and/or external committees.
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• Chair company committees as needed.
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• Interpret medical policies and clinical guidelines.
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• Develop and propose new medical policies based on changes in healthcare.
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• Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
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• Identify and develop opportunities for innovation to increase effectiveness and quality.

Requirements
• MD or DO with Board certification approved by ABMS or AOA.
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• Active unrestricted medical license to practice medicine or a health profession.
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• Minimum of 10 years of clinical experience or equivalent education and experience.
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• For Health Solutions and Carelon organizations, minimum of 5 years of experience providing healthcare is required.

Nice-to-haves
• Board certification in Internal or Family medicine strongly preferred.
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• Florida medical license or the ability to obtain once hired strongly preferred.

Benefits
• Merit increases
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• Paid holidays
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• Paid Time Off
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• Incentive bonus programs
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• Medical, dental, and vision benefits
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• Short and long term disability benefits
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• 401(k) with matching
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• Stock purchase plan
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• Life insurance
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• Wellness programs
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• Financial education resources

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