Medicare Medical Director

$240,576 - $378,048/Yr

Elevance Health - Chicago, IL

Full-time - Director

Chicago, IL

Insurance Carriers and Related Activities

About the position

The Medicare Medical Director is responsible for the administration of physical and/or behavioral health medical services, ensuring that appropriate and cost-effective medical care is received. This role may involve developing and implementing programs to improve quality, cost, and outcomes, providing clinical consultation, and serving as a clinical/strategic advisor to enhance clinical operations. The director may identify cost of care opportunities and serve as a resource to staff, including Medical Director Associates. Responsibilities may also include overseeing an entire clinical program.

Responsibilities

• Supports clinicians to ensure timely and consistent responses to members and providers.
• Provides guidance for clinical operational aspects of a program.
• Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations and patients' office visits.
• May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
• 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.

Requirements

• Requires MD or DO and Board certification approved by one of the following certifying boards: American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
• Must possess an active unrestricted medical license to practice medicine or a health profession.
• Must be located in a state or territory of the United States when conducting utilization review or appeals consideration, 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 that would provide an equivalent background.
• For Health Solutions and Carelon organizations (including behavioral health), a minimum of 5 years of experience providing health care is required.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid Time Off
• Paid holidays
• Medical, dental, and vision insurance
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources