Cardiology Medical Director

Elevance Health•Indianapolis, IN

7d•Remote

About The Position

Clinical Operations Medical Director Carelon MBM Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: Opportunities for both Full Time and Part Time work 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 Medical Director, Cardiology is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers. In this role, you will participate in pre-authorization and quality improvement solutions for both specialized cardiology and vascular surgery. This includes but is not limited to cardiac procedures such as coronary angiography, percutaneous coronary interventions, implanted cardiac devices, electrophysiology procedures and arterial/venous endovascular interventions. How you will make an impact: 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 company medical policies when making medical necessity decisions. Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation. Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, state mandated policies, and CMS Coverage Determinations, as applicable. Perform physician-level case review of utilization requests for procedures and interventions listed above. Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging, and appropriate sites of service. Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria. Provide education regarding applicable clinical criteria.

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.
Minimum of 1 year of experience with clinical case reviews for medical necessity. The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only; Cardiology, Oncology, and Interventional Pain specialties.
Board certification in a medical specialty required.

Nice To Haves

Board Certification in Cardiovascular Disease, Interventional Radiology or Vascular Surgery by the American Board of Internal Medicine or Surgery.
3-5 years of clinical practice experience past fellowship training is desirable.
Demonstrated knowledge of current practice standards in Vascular surgery or Cardiology.

Responsibilities

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 company medical policies when making medical necessity decisions.
Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation.
Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, state mandated policies, and CMS Coverage Determinations, as applicable.
Perform physician-level case review of utilization requests for procedures and interventions listed above.
Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging, and appropriate sites of service.
Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.