Medical Director -National Accounts

Elevance Health•Atlanta, NY

23h•Remote

About The Position

The Medical Director - National Accounts is responsible for serving as the Operational Medical Director for care management models for National Account clients. The medical director will be responsible for supporting the clinical vision and implementation to improve the health of the people served. The medical director supports product strategy/design through medical management that impacts healthcare quality, cost, and outcomes, and improving access to health improvement tools offered to clients/members. The medical director provides clinical expertise in all aspects of utilization review and case management. Provides input on clinical relevance to account reporting regarding the use of medical services by members. Involved in identifying and managing medical utilization trends, emerging trends, and market changes that impact the client and members. Responsible for proactively identifying and solutioning with account management and Sales RVP Medical Directors.

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.
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

Indiana MD license or compact state multi-licensure is preferred but not exclusive.
Board certification preferably in a Primary Health Specialty, Family or Internal medicine, Pediatrics or Surgery (surgical specialty).
Knowledge and experience with population or segment health management is a plus.
Knowledge of the health insurance industry and the National Accounts segment is preferred.

Responsibilities

Serving as the Operational Medical Director for care management models for National Account clients.
Supporting the clinical vision and implementation to improve the health of the people served.
Supporting product strategy/design through medical management that impacts healthcare quality, cost, and outcomes.
Improving access to health improvement tools offered to clients/members.
Providing clinical expertise in all aspects of utilization review and case management.
Providing input on clinical relevance to account reporting regarding the use of medical services by members.
Identifying and managing medical utilization trends, emerging trends, and market changes that impact the client and members.
Proactively identifying and solutioning with account management and Sales RVP Medical Directors.
Directly involved in Utilization Management and Case Management.
Daily case reviews for both utilization and case management issues (80/20 split).
Consistent adoption and implementation of all medical policies used for operational reviews.
Leading multidisciplinary rounds for case management/complex clinical management.
Peer-to-peer outreach for both utilization reviews and for case management consultation with treating providers.
Clinical report reviews, trend management, benefit design consultation, and supporting overall clinical performance guarantee success.
Supporting all state-specific requirements that apply for each state where there is business.