Clinical Operations Medical Director

Elevance Health - Chicago, IL

Full-time - Senior

Remote - Chicago, IL

11-50 employees

Insurance Carriers and Related Activities

About the position

The Clinical Operations Medical Director plays a crucial role in supporting the medical management staff by ensuring timely and consistent medical decisions for members and providers. This position involves participating in pre-authorization and quality improvement solutions specifically for specialized cardiology and vascular surgery procedures. The role requires making medical necessity determinations, conducting peer-to-peer consultations, and ensuring adherence to company medical policies.

Responsibilities

• Ensure timely completion of clinical case reviews for board certified specialty.
• Make physician-to-physician calls to gather medically appropriate information for medical necessity determinations.
• Make medical necessity determinations for grievances and appeals appropriate for specialty.
• Ensure consistent use of company medical policies in medical necessity decisions.
• Bring to supervisors' attention any case review decisions requiring Medical Director review or policy interpretation.
• Determine medical necessity of requests using applicable clinical criteria, including AIM Appropriateness Guidelines and CMS Coverage Determinations.
• Perform physician-level case review of utilization requests for specified procedures and interventions.
• Conduct peer-to-peer consultations with ordering physicians and advanced practice providers regarding established guidelines and standards of care.
• Discuss clinically appropriate alternative treatments and provide education regarding applicable clinical criteria.

Requirements

• MD degree required.
• Minimum of 1 year of experience with clinical case reviews for medical necessity.
• Board certification in a medical specialty required.

Nice-to-haves

• Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.
• Board Certification in Cardiovascular Disease, Interventional Radiology or Vascular Surgery by the American Board of Internal Medicine or Surgery.
• 3-5 years of clinical practice experience past fellowship training is desirable.
• Demonstrated knowledge of current practice standards in Vascular surgery or Cardiology.

Benefits

• Sign-on bonus of $10,000
• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical, dental, and vision insurance
• Short and long term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources