Medical Director – Physical Medicine and Rehabilitation

Elevance Health•Atlanta, GA

2d•Remote

About The Position

The Medical Director – Physical Medicine and Rehabilitation works with the Home Care (HC) Durable Medical Equipment (DME) team, which reviews high-cost DME requests. The Medical Director evaluates cases to determine the appropriateness of services, particularly in a Medicaid context, and collaborates with a small, distributed team across multiple states. The role requires cross-functional collaboration and effective communication. The position enables associates to work virtually full-time, except for required in-person training sessions. Candidates must be within a reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law; alternate locations may be considered. The Medical Director supports clinical review operations, interprets medical policies and clinical guidelines, and leads clinical and non-clinical activities affecting health care quality, cost, and outcomes.

Requirements

MD or DO degree.
Board certification approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable to duties performed.
Active, unrestricted medical license to practice medicine or a health profession.
When conducting utilization review or appeals consideration, must be located in a U.S. state or territory, unless expressly allowed otherwise by state or federal law or regulation; cannot be located on a U.S. military base, vessel, or embassy in or outside the United States.
At least 10 years of clinical experience, or an equivalent combination of education and experience.
For Health Solutions and Carelon organizations, including behavioral health, at least 5 years of experience providing health care.
Additional experience may be required by state contracts or regulations when the Medical Director is filling a role required by a state agency.

Nice To Haves

Utilization management (UM) experience.
Durable Medical Equipment (DME) experience.
Board certification in Physical Medicine and Rehabilitation.

Responsibilities

Support clinicians in providing timely and consistent responses to members and providers.
Provide guidance on clinical operational aspects of a program.
Conduct 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.
Serve as a resource and consultant for other areas of the company.
May represent the company to external entities and/or serve on internal or external committees.
May chair company committees.
Interpret medical policies and clinical guidelines.
May develop and propose new medical policies based on changes in healthcare.
Lead, develop, direct, and implement clinical and non-clinical activities that affect health care quality, cost, and outcomes.
Identify and develop opportunities for innovation to increase effectiveness and quality.