Medical Director - Surgery (including Dermatology or Ophthalmology or Gastroenterology)

Elevance Health • Indianapolis, IN

1d • Remote

About The Position

Clinical Operations Medical Director Carelon Medical Benefit Management Radiology Benefit Management Surgery (Including: General, Dermatology, Ophthalmology, or Gastroenterology) Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. Virtual: 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. The Clinical Operations Medical Director - Surgery is responsible for performing pre-authorizations and providing quality improvement solutions involving surgical procedures.

Requirements

• Requires MD and/or DO, completion of training in General Surgery, Surgical Subspecialties, or specialties that perform interventional procedures.
• Requires board certification by either the American Board of Medical Specialties or the American Osteopathic Association Specialties.
• Requires a current, valid, active and unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s).
• Requires a minimum of 5 years of clinical experience.

Nice To Haves

• Experience with utilization management, specifically with CMS guidelines preferred.

Responsibilities

• Determines the medical necessity of requests using clinical criteria.
• Performs physician-level case review of surgical utilization requests.
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service.
• Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options.
• Performs first level provider appeals for coverage decisions.
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management of conditions and surgical procedures.
• Participates in physician team meetings.
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines.

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.

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: Ph.D. or professional degree