Medical Director – Physical Medicine and Rehabilitation

Elevance Health•Indianapolis, IN

3d•Remote

About The Position

The Medical Director – Physical Medicine and Rehabilitation works with Elevance Health’s Home Care Durable Medical Equipment team, which reviews high-cost DME requests. The role evaluates cases to determine the appropriateness of services, particularly in a Medicaid context, and collaborates with a small, distributed team across multiple states. The position is described as primarily virtual full-time, with required in-person training sessions; candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted, although alternate locations may be considered. The Medical Director supports clinicians in providing timely, consistent responses to members and providers; guides clinical operations; conducts peer-to-peer clinical reviews and may conduct appeal reviews; advises other company areas; interprets and may develop medical policies and clinical guidelines; and leads clinical and non-clinical activities affecting health care quality, cost, and outcomes. The role may also involve representing the company to external entities, serving on committees, and chairing committees.

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 being performed.
Active, unrestricted medical license to practice medicine or a health profession.
Unless expressly allowed by state or federal law or regulation, must be located in a U.S. state or territory when conducting utilization review or appeals consideration and cannot be located on a U.S. military base, vessel, or embassy.
Minimum of 10 years of clinical experience, or an equivalent combination of education and experience.
For Health Solutions and Carelon organizations, including behavioral health, a minimum of 5 years of experience providing health care is required.
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 to ensure timely and consistent responses to members and providers.
Provide guidance for 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 impact health care quality, cost, and outcomes.
Identify and develop opportunities for innovation to increase effectiveness and quality.
Evaluate high-cost Durable Medical Equipment requests to determine the appropriateness of services, particularly within a Medicaid context.