Orthopedic Surgery Associate Medical Director

Elevance Health • Ashburn, VA

4d • Remote

About The Position

Clinical Operations Associate Medical Director Orthopedic Surgery Virtual: 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. A proud member of the Elevance Health family of companies, Carelon Behavioral Health, formerly Beacon Health Options, offers superior clinical mental health and substance use disorder management, a comprehensive employee assistance program, work/life support, specialty programs for autism and depression, and insightful analytics to improve the delivery of care. The Clinical Operations Associate Medical Director - Orthopedic Surgery is responsible for performing pre-authorizations and providing quality improvement solutions for musculoskeletal procedures involving the joints. How you will make an impact: Determines the medical necessity of requests using clinical criteria. Performs physician-level case review of musculoskeletal utilization requests. Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service. Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments. Performs first level provider appeals of coverage decisions. Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management. Participates in physician team meetings. Participates in groups that develop, revise and enhance clinical appropriateness guidelines.

Requirements

• Requires MD or DO and Board certification by the American Board of Orthopedic Surgery or American Osteopathic Board of Orthopedic Surgery.
• Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s).
• Experience performing standard orthopedic procedures independently.

Nice To Haves

• Minimum of 5 years of clinical practice experience past fellowship training preferred.
• Extensive orthopedic surgery experience preferred.
• Experience with utilization management, especially with CMS guidelines preferred.

Responsibilities

• Determines the medical necessity of requests using clinical criteria.
• Performs physician-level case review of musculoskeletal utilization requests.
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.
• Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments.
• Performs first level provider appeals of coverage decisions.
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management.
• Participates in physician team meetings.
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Ph.D. or professional degree
• Number of Employees: 5,001-10,000 employees