Medical Director

Elevance Health•Tampa, FL

7d•Remote

About The Position

The Medical Director is responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received. 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. May be responsible for an entire clinical program. Supports clinicians to ensure timely and consistent responses to members and providers. Guides clinical operational aspects of a program. Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations and patient's 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 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. Works independently with oversight from immediate manager. May be responsible for an entire clinical program and/or independently perform clinical reviews. The Medical Director typically has program management responsibilities including clinical policy development, program development/implementation, and overseeing clinical/non-clinical activities.

Requirements

MD/DO and Board certification approved by the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable to duties being performed.
Active unrestricted medical license to practice medicine or a health profession.
Located in a state or territory of the United States when conducting utilization review or an appeals consideration (unless expressly allowed by state or federal law, or regulation), 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.
Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.
Ability to meet necessary internet speed requirements and adhere to work-at-home agreements.
Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills (for URAC accredited areas).

Nice To Haves

Utilization Management experience is a plus.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Responsibilities

Administration of physical and/or behavioral health medical services to ensure appropriate and cost-effective medical care.
Developing and implementing programs to improve quality, cost, and outcomes.
Providing clinical consultation and serving as a clinical/strategic advisor to enhance clinical operations.
Identifying cost of care opportunities.
Serving as a resource to staff, including Medical Director Associates.
Supporting clinicians to ensure timely and consistent responses to members and providers.
Guiding clinical operational aspects of a program.
Conducting peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations.
Conducting peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Serving as a resource and consultant to other areas of the company.
Representing the company to external entities and/or serving on internal and/or external committees.
Chairing company committees.
Interpreting medical policies and clinical guidelines.
Developing and proposing new medical policies based on changes in healthcare.
Leading, developing, directing, and implementing clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
Identifying and developing opportunities for innovation to increase effectiveness and quality.
Working independently with oversight from immediate manager.
Being responsible for an entire clinical program and/or independently performing clinical reviews.
Having program management responsibilities including clinical policy development, program development/implementation, and overseeing clinical/non-clinical activities.