Location: This is a remote position. Candidates must live within 50 miles of an Elevance Health location.
Build the Possibilities. Make an extraordinary impact.
Responsible for providing day-to-day guidance, support, and leadership for clinical and/or quality activities under the guidance of a Medical Director. May be responsible for supporting one or more Medical Directors in ensuring clinical integrity of broad and significant clinical programs. May perform clinical review.
How you will make an impact:
May provide clinical guidance for programs.
Supports clinicians to ensure timely and consistent responses to members and providers.
Conducts peer-to-peer clinical reviews with attending physicians or other ordering providers to discuss review determinations, and patients' office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
May participate in a physician on-call rotation for a 24x7 unit.
May assist in the practitioner appeal reviews, appropriateness criteria reviews, medical technology assessments, setting and implementing QI initiatives, and practitioner/provider credentialing.
Under direction, may be responsible for the administration of medical services for company health plans including medical policies.
Serves as a resource and consultant to other areas of the company.
May interpret existing medical policy.
May be required to represent the company to external entities and/or serve on internal and/or external committees.
Minimum Requirements:
Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
Must possess an active unrestricted medical license to practice medicine or a health profession.
Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
