Associate Medical Director, Clinical Operations

$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 at Elevance Health is a pivotal role responsible for overseeing the medical necessity determinations for various outpatient services, including diagnostic imaging and cardiac testing. This position involves conducting physician-level case reviews, engaging in peer-to-peer discussions with healthcare providers, and ensuring adherence to established medical guidelines and policies. The role supports the medical management staff in delivering timely and accurate medical decisions to members and providers, contributing to the overall mission of improving healthcare outcomes.

Responsibilities

• Perform physician-level case review of high-tech diagnostic imaging, upper endoscopy, surgical procedures, and sleep testing.
• Determine medical necessity of requests using established medical necessity guidelines and health plan policies.
• Conduct peer-to-peer discussions with ordering physicians to provide education on guidelines and standards of care.
• Suggest alternative services to providers when appropriate.
• Document pre-certification reviews accurately in the pre-certification application.
• Maintain current knowledge of diagnostic imaging modalities and new technologies.
• Assist pre-certification nurses in understanding appropriate utilization of covered modalities.
• Participate in physician team meetings and committees for clinical guideline revisions.
• Perform first level provider appeals for adverse determinations.
• Adhere to all protocols, policies, and procedures of Carelon Medical Benefits Management.

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 preferred.
• Board Certification by American Board of Medical Specialties in Internal Medicine, Family Medicine, or Emergency Medicine preferred.
• Demonstrated knowledge of current practice standards in specialty.
• Strong oral communication and interpersonal skills.
• Computer literacy with the ability to learn new applications.
• Strong analytical skills and ability to multi-task.
• Ability to work independently and in a team environment.
• Ability to thrive in a dynamic, fast-paced environment.

Nice-to-haves

• Experience in utilization review or medical management.
• Familiarity with Medicare Coverage Determinations and state mandates.

Benefits

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