Plan Performance Medical Director

Elevance Health • Brainerd, MN

2d • Hybrid

About The Position

Plan Performance Medical Director This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. 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.” The Plan Performance Medical Director is responsible for serving as the lead clinician for a plan. Responsible for the administration of medical services for the company health plan including the overall medical policies or clinical guidelines of the plan to ensure the appropriate and most cost effective medical care is received. Drives direction of the plan related to cost of care and other plan directives. Works with the market plan president during meetings with State Regulator. How you will make an impact: Supports the Medical Management staff 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 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. Interpret existing policies or clinical guidelines and develop new policies based on changes in the healthcare or medical arena. Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care. Identifies and develops opportunities for innovation to increase effectiveness and quality. Provides expertise, captures and shares best practices across regions to other medical directors. May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.

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.
• A minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

• Thorough understanding of Medicaid policies in the District of Columbia strongly preferred.
• Established rapport within the DC regulatory community strongly preferred.
• Extensive experience working in managed care leadership strongly preferred.
• Experience supporting and collaborating within the LTSS (Long-Term Services and Support) strongly preferred.
• Associate in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

Responsibilities

• Supports the Medical Management staff 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 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.
• Interpret existing policies or clinical guidelines and develop new policies based on changes in the healthcare or medical arena.
• Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care.
• Identifies and develops opportunities for innovation to increase effectiveness and quality.
• Provides expertise, captures and shares best practices across regions to other medical directors.
• May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.

Benefits

• Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources

What This Job Offers

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