Medical Director- Utilization Management for Carelon Health

Elevance Health • Cerritos, CA

396d • $263,488 - $395,232 • Hybrid

About The Position

The Medical Director for Utilization Management at Elevance Health is responsible for overseeing the administration of physical and behavioral health medical services, ensuring that members receive appropriate and cost-effective medical care. This role involves developing and implementing programs to improve quality, cost, and outcomes, providing clinical consultation, and serving as a strategic advisor to enhance clinical operations. The position requires collaboration with clinicians and external entities, conducting peer-to-peer clinical reviews, and interpreting medical policies and clinical guidelines.

Requirements

• MD or DO with Board certification from a recognized certifying board.
• Active unrestricted medical license to practice in California.
• Minimum of 10 years of clinical experience, or equivalent education and experience.
• Minimum of 5 years of experience providing healthcare for Health Solutions and Carelon organizations.

Responsibilities

• Support clinicians to ensure timely and consistent responses to members and providers.
• Provide guidance for clinical operational aspects of a program.
• Conduct peer-to-peer clinical reviews with attending physicians or other providers.
• Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers.
• Serve as a resource and consultant to other areas of the company.
• Represent the company to external entities and/or serve on internal and/or external committees.
• Interpret medical policies and clinical guidelines.
• Develop and propose new medical policies based on changes in healthcare.
• Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes.
• Identify and develop opportunities for innovation to increase effectiveness and quality.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Industry: Insurance Carriers and Related Activities
• Education Level: Ph.D. or professional degree
• Number of Employees: 11-50 employees