Associate Medical Director, Clinical Operations (Surgery)

$203,507 - $203,507/Yr

Elevance Health - Chicago, IL

Full-time - Senior

Remote - Chicago, IL

11-50 employees

Insurance Carriers and Related Activities

About the position

The Associate Medical Director, Clinical Operations (Surgery) at Carelon Medical Benefits Management is responsible for overseeing the medical management staff to ensure timely and consistent medical decisions regarding surgical procedures. This role involves determining the medical necessity of requests, conducting peer-to-peer consultations, and providing education on clinical criteria. The position is remote, but candidates should reside within 50 miles of an Elevance Health PulsePoint location.

Responsibilities

• Determine medical necessity of requests using applicable clinical criteria.
• Perform physician-level case review of utilization requests involving radiology imaging requests, endoscopies, surgical procedures, and other codes.
• Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses regarding established guidelines and accepted standards of care.
• Discuss clinically appropriate alternative treatments, imaging studies, and sites of care with ordering providers.
• Provide education regarding applicable clinical criteria.
• Perform first level provider appeals of coverage decisions.
• Demonstrate and maintain knowledge of applicable clinical criteria and relevant Carelon Medical Benefits Management policies.
• Demonstrate and maintain knowledge of applicable ICD-10, HCPCS, and CPT coding guidelines as it relates to surgical services and procedures.
• Provide support and educate internal clinical and non-clinical staff on appropriate surgical diagnoses, treatments, and management.
• Actively participate in physician team meetings and groups that develop, revise, and enhance clinical appropriateness guidelines.
• Obtain additional state licensure based on state regulations and health plan needs.
• Adhere to all Carelon Medical Benefits Management protocols, policies, and procedures.

Requirements

• MD and Board certification in a medical specialty required.
• Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.
• American Board of Medical Specialties board certification in General Surgery or other primary surgical specialties such as ENT, Plastic Surgery, Vascular Surgery, Cardio-thoracic, Trauma or Transplant surgical specialties.
• 3-5 years of clinical practice experience past fellowship training is desirable.
• Demonstrated knowledge of current practice standards in surgical care.
• Strong oral communication and interpersonal skills.
• Computer literacy with the ability to learn new applications.
• Strong analytical skills.
• Ability to multi-task.
• Ability to work both independently and in a team environment.
• Ability to work in a dynamic, fast-paced environment.

Nice-to-haves

• Preferred interest in Surgical utilization review.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid Time Off
• Medical, dental, vision benefits
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources