Associate Medical Director - Orthopedic Surgery

$215,245 - $407,821/Yr

Elevance Health - Seven Hills, OH

Full-time - Mid Level

Seven Hills, OH

Insurance Carriers and Related Activities

About the position

The Clinical Ops Associate Medical Director - Orthopedic Surgery is responsible for performing pre-authorizations and providing quality improvement solutions for musculoskeletal procedures involving the joints. This position is virtual, requiring candidates to reside within 50 miles of an Elevance Health Pulse Point location. The work schedule is Monday to Friday from 8:00 am to 5:00 pm, depending on the candidate's time zone. The role involves determining the medical necessity of requests using clinical criteria, performing physician-level case reviews, conducting peer-to-peer consultations, providing education on clinical criteria, and participating in physician team meetings.

Responsibilities

• Determines the medical necessity of requests using clinical criteria.
• Performs physician-level case review of musculoskeletal utilization requests.
• Conducts peer-to-peer consultation with ordering physicians, physician assistants, and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging, and appropriate sites of service.
• Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments.
• Performs first level provider appeals of coverage decisions.
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management.
• Participates in physician team meetings.
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines.

Requirements

• Requires MD or DO and Board certification by the American Board of Orthopedic Surgery or American Osteopathic Board of Orthopedic Surgery.
• Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s).
• Experience performing standard orthopedic procedures independently.

Nice-to-haves

• Minimum of 3 years of clinical practice experience past fellowship training preferred.
• Extensive orthopedic surgery experience preferred.
• Experience with utilization management, especially with CMS guidelines preferred.

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