Medical Director-Family/Internal Medicine

Elevance Health•St. Louis, MO

1d•Hybrid

About The Position

This Medical Director role offers virtual full-time work, with the exception of mandatory in-person training sessions, providing flexibility and autonomy while ensuring essential onboarding and skill development. Candidates must be within a reasonable commuting distance of the posting locations (Colorado & Columbus, OH) unless an accommodation is legally granted. The Medical Director is responsible for administering physical and/or behavioral health medical services to ensure appropriate and cost-effective care. This includes developing and implementing programs for quality, cost, and outcome improvement, providing clinical consultation, serving as a clinical/strategic advisor for clinical operations, and identifying cost-of-care opportunities. The role also involves serving as a resource for staff, including Medical Director Associates, and may encompass responsibility for an entire clinical program. The Medical Director typically manages programs, including clinical policy development, program development/implementation, and overseeing clinical and non-clinical activities.

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.
A 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, a 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.

Nice To Haves

Experience caring for patients in following specialties: Family Practice, Internal Medicine, and General Surgery are strongly preferred.
Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Supports clinicians to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Serves as a resource and consultant for 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.