Medical Director - Florida Medicare (part-time)

Elevance Health•Tampa, FL

1d•Remote

About The Position

The Medical Director is responsible for utilization management, medical necessity clinical reviews of inpatient and outpatient authorizations, appeals medical necessity reviews, and peer-to-peer clinical discussions. The role also participates in assigned committees, including peer review, credentialing, and quality committees, and may contribute to cost-of-care initiatives and lead assigned projects. This role supports clinicians in providing timely, consistent responses to members and providers; provides guidance on clinical program operations; and conducts utilization management reviews using nationally recognized criteria such as MCG, InterQual, and CMS guidelines. The Medical Director collaborates with UM nurses and case managers, discusses medical necessity decisions and care alternatives with treating physicians, and ensures reviews are completed accurately and on time in compliance with regulations, NCQA, and company standards. Additional duties may include serving as a consultant or company representative, serving on or chairing committees, interpreting and developing medical policies and clinical guidelines, and leading clinical and non-clinical initiatives that affect healthcare quality, cost, and outcomes. Weekend and holiday coverage is required during assigned rotations to support UM operations and timely case processing. The position enables associates to work virtually full-time, except for required in-person training. Candidates must be within reasonable commuting distance of the posting location unless an accommodation is granted; candidates near a Florida location are preferred, and alternate locations may be considered. Weekend on-call expectations apply.

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 Florida medical license to practice medicine or a health profession.
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 healthcare; additional experience may be required by state contracts or regulations.
When conducting utilization review or appeals consideration, must be located in a U.S. state or territory, and not on a U.S. military base, vessel, or embassy, unless expressly allowed by applicable law or regulation.
Available for weekend on-call expectations and assigned weekend and holiday rotations.
Within reasonable commuting distance of the posting location unless an accommodation is granted; candidates near a Florida location are preferred.

Nice To Haves

Previous Medicare experience.
Internal Medicine, Family Medicine, or other adult medicine training.

Responsibilities

Support clinicians in providing timely and consistent responses to members and providers.
Provide guidance for clinical operational aspects of a program.
Conduct utilization management reviews to determine medical necessity and appropriateness of care using nationally recognized criteria, including MCG, InterQual, and CMS guidelines.
Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
Conduct peer-to-peer discussions with treating physicians about medical necessity decisions and care alternatives.
Complete reviews accurately and on time in compliance with state and federal regulations, NCQA, and company standards.
Serve as a resource and consultant to other areas of the company.
Represent the company to external entities and serve on internal or external committees as required.
Chair company committees as required.
Interpret medical policies and clinical guidelines; develop and propose new medical policies based on changes in healthcare as appropriate.
Lead, develop, direct, and implement clinical and non-clinical activities affecting healthcare quality, cost, and outcomes.
Identify and develop opportunities for innovation to increase effectiveness and quality.
Provide weekend on-call and assigned weekend and holiday coverage to support UM operations and timely case processing.
Participate in assigned committees, including peer review, credentialing, and quality committees.
Participate in cost-of-care initiatives and lead assigned projects as requested.