National Accounts Medical Director

Elevance Health•Waukesha, IN

14d•Hybrid

About The Position

National Accounts Medical Director Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Alternate locations may be considered. The National Accounts Medical Director is responsible for serving as the Operational Medical Director for our care management models for our National Account clients. The medical director will be responsible for supporting the clinical vision and implementation to deliver an improvement in the health of the people we serve. The medical director supports product strategy/design through medical management that impact health care quality, cost, and outcomes, and improving access to the health improvement tools offered to clients/ members. The medical director provides clinical expertise in all aspects of utilization review and case management. Provides input on the clinical relevance to account reporting regarding use of medical services by members. Involved in identifying and managing medical utilization trends, emerging trends and market changes that impact the client and members. Responsible for proactively identifying and solutioning with account management, Sales RVP Medical Directors. How you will make an impact : Day to day clinical responsibilities means that the medical director is directly involved in Utilization Management and Case Management. Daily case reviews for both utilization and case management issues. (80/20 split) Consistent adoption and implementation of all medical policies used for operational reviews. Leading multidisciplinary rounds for case management /complex clinical management. Peer-to-peer outreach for both utilization reviews and also for case management consultation with treating providers. Clinical report reviews, trend management, benefit design consultation, and supporting overall clinical performance guarantee success. The medical director will be responsible for supporting all state specific requirements that apply for each state where there is our business.

Requirements

Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, 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.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an 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, which would provide an equivalent background.
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required.
Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Nice To Haves

Indiana MD license or compact state multi-licensure is preferred but not exclusive.
Board certification preferably in a Primary Health Specialty, Family or Internal medicine or Surgery (surgical specialty).
Knowledge and experience with population or segment health management is a plus.
Knowledge of the health insurance industry and the National Accounts segment is preferred.

Responsibilities

Directly involved in Utilization Management and Case Management
Daily case reviews for both utilization and case management issues. (80/20 split)
Consistent adoption and implementation of all medical policies used for operational reviews.
Leading multidisciplinary rounds for case management /complex clinical management.
Peer-to-peer outreach for both utilization reviews and also for case management consultation with treating providers.
Clinical report reviews, trend management, benefit design consultation, and supporting overall clinical performance guarantee success.
Responsible for supporting all state specific requirements that apply for each state where there is our business.