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.
,
Support clinicians to ensure timely and consistent responses to members and providers.
,
Provide guidance for clinical operational aspects of a program.
,
Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
,
Serve as a resource and consultant to other areas of the company.
,
Represent the company to external entities and/or serve on internal and/or external committees.
,
Chair company committees as needed.
,
Interpret medical policies and clinical guidelines.
,
Develop and propose new medical policies based on changes in healthcare.
,
Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
,
Identify and develop opportunities for innovation to increase effectiveness and quality.
Requirements
MD or DO with Board certification approved by ABMS or AOA.
,
Active unrestricted medical license to practice medicine or a health profession.
,
Minimum of 10 years of clinical experience or equivalent education and experience.
,
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.
,
Florida medical license or the ability to obtain once hired strongly preferred.
Benefits
Merit increases
,
Paid holidays
,
Paid Time Off
,
Incentive bonus programs
,
Medical, dental, and vision benefits
,
Short and long term disability benefits
,
401(k) with matching
,
Stock purchase plan
,
Life insurance
,
Wellness programs
,
Financial education resources
Apply Now
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.
,
Support clinicians to ensure timely and consistent responses to members and providers.
,
Provide guidance for clinical operational aspects of a program.
,
Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
,
Serve as a resource and consultant to other areas of the company.
,
Represent the company to external entities and/or serve on internal and/or external committees.
,
Chair company committees as needed.
,
Interpret medical policies and clinical guidelines.
,
Develop and propose new medical policies based on changes in healthcare.
,
Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
,
Identify and develop opportunities for innovation to increase effectiveness and quality.
Requirements
MD or DO with Board certification approved by ABMS or AOA.
,
Active unrestricted medical license to practice medicine or a health profession.
,
Minimum of 10 years of clinical experience or equivalent education and experience.
,
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.
,
Florida medical license or the ability to obtain once hired strongly preferred.
Benefits
Merit increases
,
Paid holidays
,
Paid Time Off
,
Incentive bonus programs
,
Medical, dental, and vision benefits
,
Short and long term disability benefits
,
401(k) with matching
,
Stock purchase plan
,
Life insurance
,
Wellness programs
,
Financial education resources
Apply Now