Medical Director - Florida Medicare (part-time)

Elevance Health•Miami, FL

13d•Hybrid

About The Position

The Medical Director is responsible for utilization management, medical-necessity clinical reviews of inpatient and outpatient authorizations, appeals reviews, and peer-to-peer clinical discussions. The role also involves active participation in assigned committees, such as peer review, credentialing, and quality committees. The Medical Director may participate in cost-of-care initiatives and lead assigned projects. The position supports clinicians in providing timely, consistent responses to members and providers and offers guidance on clinical operational aspects of a program. The Medical Director uses nationally recognized criteria, including MCG, InterQual, and CMS guidelines, and works with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays. Reviews must be completed accurately and on time in accordance with state and federal regulations, NCQA, and company standards. The Medical Director also serves as a resource and consultant to other company areas, may represent the company to external entities, and may serve on or chair committees. Responsibilities include interpreting medical policies and clinical guidelines; proposing new policies as healthcare changes; and leading, developing, directing, and implementing activities that affect healthcare quality, cost, and outcomes. The role identifies opportunities for innovation to improve effectiveness and quality. The position is described as virtually full-time, except for required in-person training. Candidates are expected to live within reasonable commuting distance of a posting location, with preference for candidates near a Florida location; alternate locations may be considered. Weekend on-call expectations apply, including weekend and holiday coverage during assigned rotations, to support continuity of utilization-management operations and timely case processing.

Requirements

MD or DO degree.
Board certification, where applicable to duties performed, by an American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) certifying board.
Active, unrestricted Florida medical or health-profession license.
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 is required.
Must be located in a U.S. state or territory while conducting utilization review or appeals consideration, unless expressly allowed by state or federal law or regulation; cannot be located on a U.S. military base, vessel, or embassy.
Must meet any additional experience requirements imposed by applicable state contracts or regulations.
Weekend on-call expectations and assigned weekend and holiday coverage are part of the role.

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 on 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 needed; chair company committees as needed.
Interpret medical policies and clinical guidelines, and develop and propose new medical policies based on changes in healthcare.
Lead, develop, direct, and implement clinical and non-clinical activities that affect healthcare quality, cost, and outcomes.
Identify and develop opportunities for innovation to increase effectiveness and quality.
Participate in assigned committees, including peer review, credentialing, and quality committees.
Participate in cost-of-care initiatives and lead assigned projects as needed.
Provide weekend on-call and assigned weekend and holiday rotation coverage to support utilization-management operations and timely case processing.