Associate Medical Director, Clinical Operations

$203,507 - $203,507/Yr

Elevance Health - Cerritos, CA

Full-time - Senior

Remote - Cerritos, CA

11-50 employees

Insurance Carriers and Related Activities

About the position

The Associate Medical Director, Clinical Operations at Elevance Health is responsible for overseeing the medical necessity determinations for outpatient radiology, cardiology, sleep management, and surgical procedures. This role involves conducting physician-level case reviews, engaging in peer-to-peer discussions with healthcare providers, and ensuring timely and accurate medical decisions are made in accordance with established guidelines and policies. The position is remote but requires the candidate to reside within 50 miles of an Elevance Health PulsePoint location.

Responsibilities

• Perform physician-level case review of high-tech diagnostic imaging and surgical procedures.
• Determine medical necessity of requests using established medical necessity guidelines and health plan policies.
• Conduct peer-to-peer discussions with healthcare providers to educate them on guidelines and standards of care.
• Document pre-certification reviews accurately in the pre-certification computer application.
• Maintain knowledge of diagnostic imaging modalities and new technologies in cardiac services and sleep management.
• Assist pre-certification nurses in understanding appropriate utilization of covered modalities.
• Participate in physician team meetings and contribute to clinical guideline revisions as needed.
• Perform first level provider appeals for adverse determinations.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree required.
• Board certification in a medical specialty is required.
• Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine.
• Strong oral communication and interpersonal skills.
• Demonstrated knowledge of current practice standards in specialty.
• Computer literacy with the ability to learn new applications.
• Strong analytical skills and ability to multi-task.

Nice-to-haves

• Board Certification by American Board of Medical Specialties in Internal Medicine, Family Medicine, or Emergency Medicine preferred.
• Ability to work independently and in a team environment.
• Experience in a dynamic, fast-paced environment.

Benefits

• Employee stock purchase plan
• Paid holidays
• Disability insurance
• Health insurance
• Dental insurance
• 401(k)
• Paid time off
• Vision insurance
• 401(k) matching
• Life insurance