Anticipated End Date: 2024-10-25
Position Title: Appeals and Optimization Medical Director-Medicaid
Job Description:
Medical Director-Medicaid Appeals and Optimization (FM (with Ob experience), EM, Med/Peds, Ob/Gyn)
Location: This is a hybrid position. Candidates must live within 50 miles of an Elevance Health location.
Build the Possibilities. Make an extraordinary impact.
Responsible for Medicaid appeal reviews and primary utilization management reviews for physical health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates. May be responsible for an entire clinical program.
How you will make an impact:
- Appeal Reviews.
- Primary Utilization Management Reviews.
- Supports clinicians to ensure timely and consistent responses to members and providers.
- Provides guidance for clinical operational aspects of a program.
- May conduct peer-to-peer clinical 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.
Minimum Requirements:
- 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 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.
Preferred Qualifications:
- Board certification in Family Medicine (with Ob Experience), Emergency Medicine, Med/Peds, or Ob/Gyn strongly preferred.
For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $240,576 to $412,416.
Locations: New York
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).
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.
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