- Ensures timely completion of clinical case reviews for their board certified specialty.
- Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested.
- Makes medical necessity determinations for grievance and appeals appropriate for their specialty.
- Ensures consistent use of medical policies when making medical necessity decisions.
- Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation.
- Perform physician-level case review, following initial nurse review, of sleep studies, durable medical equipment, and high-tech diagnostic imaging.
- Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.
- Requires an MD and Board certification in a medical specialty required.
- Board Certification by American Board of Medical Specialties in Sleep Medicine strongly preferred.
- 3-5 years of clinical practice experience past fellowship training is desirable
- Licensed in the state of California strongly preferred.
- 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.
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Associate Medical Director - Palo Alto, United States - Elevance Health
Description
Clinical Operations Associate Medical Director
Sleep Medicine
Carelon Medical Benefits Management
Location : This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our California Elevance Health PulsePoint locations.
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 Sleep Clinical Operations Associate Medical Directo r is a Sleep Specialist participating in pre-authorization and quality improvement solutions for sleep studies and high-tech general medicine diagnostic imaging. This position may require collaboration in other existing and future solutions. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cardiology and sleep management requests using clinical guidelines and health plan medical policy.
How you will make an impact:
Minimum Requirements:
Preferred Skills, Capabilities and Experiences:
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $162,801 to $293,055.
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 .
Associate Medical Director professionals in Palo Alto
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Aussama Khalaf Nassar
Academic Surgeon Educator