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