Medical Director-Dermatology Appeals

Elevance Health•Metairie, IN

11d•Hybrid

About The Position

Medical Director-Dermatology Appeals Location: 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. Alternate locations may be considered. 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. The Medical Director-Dermatology Appeals is responsible for the review of appeals 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: Complete appeal reviews in your specialty daily to ensure timely and consistent responses to members and providers. Provide guidance for clinical operational aspects of a program. May conduct peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations Serve 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. Interpret medical policies and clinical guidelines. May lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality cost and outcomes. Identify and develop opportunities for innovation to increase effectiveness and quality. Work independently with oversight from immediate manager. May be responsible for an entire clinical program and/or independently perform clinical reviews.

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).
Board certification in Dermatology.
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 filling a role required by a State agency.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Responsibilities

Complete appeal reviews in your specialty daily to ensure timely and consistent responses to members and providers.
Provide guidance for clinical operational aspects of a program.
May conduct peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations
Serve 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.
Interpret medical policies and clinical guidelines.
May lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality cost and outcomes.
Identify and develop opportunities for innovation to increase effectiveness and quality.
Work independently with oversight from immediate manager.
May be responsible for an entire clinical program and/or independently perform clinical reviews.

Benefits

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.

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