Medical Director- Florida Medicare Plans

Elevance Health•Doral, FL

1d•Hybrid

About The Position

Medical Director- Florida Medicare Plans 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. 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. Candidates must reside in Florida near our Miami or Tampa locations. The Medical Director will support the following Florida Medicare plans: Simply Healthcare Plans, Healthsun Plans, Freedom Health, and Optimum Healthcare Plans and will be responsible for utilization review case management for these markets. 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. How you will make an impact: Supports clinicians to ensure timely and consistent responses to members and providers. Provides guidance for clinical operational aspects of a program. Perform utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines). Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays. Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives. Ensure timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards. 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. Expectation for this role also includes weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.

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 in Florida.
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.

Nice To Haves

Bilingual- Spanish speaking preferred.
Utilization Management case review experience strongly preferred.
Previous experience working for a health plan or managed care organization preferred.
Previous Medicare experience preferred.
Internal/Family Medicine or other adult medicine training preferred.

Responsibilities

Supports clinicians to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Perform utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines).
Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.
Ensure timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards.
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.
Expectation for this role also includes weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.

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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