- Determines the medical necessity of requests using clinical criteria.
- Performs physician-level case review of musculoskeletal utilization requests.
- Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.
- Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments.
- Performs first level provider appeals of coverage decisions.
- Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management.
- Participates in physician team meetings.
- Participates in groups that develop, revise and enhance clinical appropriateness guidelines.
- Requires MD or DO and Board certification by the American Board of Neurologic Surgery or American Osteopathic Board of Neurosurgery. Additionally, American Board of Orthopedic Surgery with completion of fellowship training in Spine Surgery or American Osteopathic Board of Orthopedic Surgery with completion of fellowship training in Spine Surgery also meets the Board certification requirements for this position.
- Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s) required.
- Experience performing standard neurosurgical spine procedures independently.
- Minimum of 3 years of clinical practice experience past fellowship training preferred.
- Extensive spine surgery experience preferred.
- Experience with utilization management, especially with CMS guidelines preferred.
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Associate Medical Director - Indianapolis, United States - Elevance Health
Description
Clinical Operations Associate Medical Director
Neurosurgery
Carelon Insights/Carelon Medical Benefits Management
A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.
The Clinical Operations Associate Medical Director of Neurosurgery responsible for performing pre-authorizations and providing quality improvement solutions for musculoskeletal procedures involving the spine and/or joints, and high-tech diagnostic imaging.
How you will make an impact:
Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of 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. Our values and behaviors are the root of our culture. 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.
Elevance Health operates in a Hybrid Workforce Strategy. 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. Applicants who require accommodation to participate in the job application process may contact assistance.
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