We are currently seeking a versatile Board Certified Physician to participate in pre-authorization reviews of high-tech diagnostic imaging, cardiac testing and sleep management services. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cardiology, sleep management, endoscopies and surgical site of care requests using clinical guidelines, state mandates, health plan medical policy and Medicare Coverage Determinations.
The Associate Medical Director, Clinical Operations is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.
Location: Remote. The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.
How you will make an impact:
Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging, upper endoscopy, other surgical procedures, surgical site of care and sleep testing. Imaging modalities include CT, CTA, MRI, MRA, PET, Ultrasounds, Nuclear Medicine imaging and Cardiology diagnostic testing.
Determine medical necessity of requests using Carelon Medical Benefits Management Medical Necessity Guidelines, client-specific health plan medical policy, state mandates/policies and Medicare determinations
Conduct peer-to-peer discussions with ordering physicians, physician assistants, and nurse practitioners to provide education regarding established guidelines and accepted standards of care as they pertain to the use of diagnostic imaging studies, cardiac testing and sleep management services.
Suggest alternatives services to ordering providers when appropriate.
Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application.
Demonstrate and maintain current knowledge of modalities and new applications of known technologies for diagnostic imaging, cardiac services, upper endoscopy procedures, surgical site of care policies, and sleep management.
As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered modalities.
Participate in periodic physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of diagnostic imaging procedures, cardiac services and sleep management.
Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert.
Perform first level provider appeals as designated by the client for adverse determinations.
Obtain additional state licensure based upon business needs.
Adhere to all Carelon Medical Benefits Management protocols, policies, and procedures.
Minimum Requirements:
Requires an MD and Board certification in a medical specialty required. Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine. Board Certification by American Board of Medical Specialties - Internal Medicine, Family Medicine and Emergency Medicine.
Preferred Skills, Capabilities, and Experiences:
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
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment
.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $97.84/hr - $135.02/hr
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
