- Supports clinicians to ensure timely and consistent responses to members and providers.
- Provides guidance for clinical operational aspects of a program.
- Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients office visits with providers and external physicians.
- May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
- Serves as a resource and consultant to other areas of the company.
- May be required to represent the company to external entities and/or serve on internal and/or external committees.
- May chair company committees. Interprets medical policies and clinical guidelines.
- May develop and propose new medical policies based on changes in healthcare.
- Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
- Identifies and develops opportunities for innovation to increase effectiveness and quality
- This level may provide oversight, direction, and guidance to Medical Director Associates.
- Works independently with oversight from immediate manager.
- May be responsible for an entire clinical program and/or independently performs clinical reviews.
- The Medical Director typically has program management responsibilities including clinical policy development, program development/implementation, and overseeing clinical/non-clinical activities.}
- Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
- Must possess an active unrestricted medical license to practice medicine or a health profession.
- Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
- Minimum of 10 years of internal medicine or family medicine clinical experience; or any combination of education and experience, which would provide an equivalent background. For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required.
- Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.
- Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.
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UM Medical Director - Nashville, United States - Elevance Health
Description
Wellpoint, formerly Amerigroup, is a proud member of Elevance Health's family of brands, offering Medicaid and Medicare plans in several states.
This position will work a hybrid model (remote and office). Ideal candidates must live within 50 miles of one of our Elevance Health locations.
The Medical Director is responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received.
How you will make an impact:
The following are level distinctions not required for posting.
Minimum requirements:
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler.
We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates.
They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week.
Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.
UM Medical Director professionals in Nashville
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Qingguo Wang
Data, Computation, NGS, sequencing, bioinformatics