Plan Performance Medical Director- New York Commercial

Elevance Health•Morristown, NJ

17h•Hybrid

About The Position

Plan Performance Medical Director- New York Commercial 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. Candidates must live within commutable distance to our NY or NJ locations. The New York Plan Performance Medical Director serves as the Chief Medical Officer for the health plan's Commercial business. This individual is responsible for oversight of medical services for members including the overall medical policies or clinical guidelines of the plan to ensure that appropriate and most cost-effective medical care is received. They will work closely with the market plan president and leadership team to align clinical operations in pursuit of shared objectives How you will make an impact: Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care. Supports new and existing customers by delivering clinical insights and recommendations that enhance the value-proposition of clinical programs. Identifies and develops opportunities for innovation to increase effectiveness and quality. Provides expertise, captures and shares best practices across regions to other medical directors. Provides guidance for clinical operational aspects of a program. Interprets existing policies or clinical guidelines and supports new policies based on changes in the healthcare or medical arena. Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations. May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations. May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees. Travels to worksite and other locations as necessary.

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).
Requires 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.

Nice To Haves

Ability to obtain a New York medical license after hire.
3 years of managed care experience preferred.
Consulting experience preferred.
Utilization management experience preferred.
Master’s Degree preferred. (MBA, MPH, etc.)

Responsibilities

Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care.
Supports new and existing customers by delivering clinical insights and recommendations that enhance the value-proposition of clinical programs.
Identifies and develops opportunities for innovation to increase effectiveness and quality.
Provides expertise, captures and shares best practices across regions to other medical directors.
Provides guidance for clinical operational aspects of a program.
Interprets existing policies or clinical guidelines and supports new policies based on changes in the healthcare or medical arena.
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.
Travels to worksite and other locations as necessary.