Plan Performance Medical Director

Elevance Health•Lubbock, TX

3d•Hybrid

About The Position

Plan Performance 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. Alternate locations can 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 serves as a lead clinician and oversees the administration of medical services for the individual ACA health plans across 17 states. This role involves managing the overall medical policies and clinical guidelines to ensure appropriate and cost-effective care. The Director also leads initiatives to direct the plan regarding cost of care and other strategic directives. Additionally, this position involves collaborating with market plan presidents during meetings with state regulators. 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. Interprets existing policies or clinical guidelines and develops 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.
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 URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Travels to worksite and other locations as necessary.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Nice To Haves

Experience with clinical finance data, as well as medical cost and trend analysis.
Strong communication skills, including both presentation and writing abilities.
Proficiency in Excel and PowerPoint.

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.
Interprets existing policies or clinical guidelines and develops 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.