Carelon Medical Benefits Management - Sleep - Associate Medical Director
Carelon Medical Benefits Management is currently seeking a Board-Certified Sleep Medicine physician.
Your Talent. Our Vision. At Carelon Medical Benefits Management, a proud member of the Carelon family of companies a subsidiary of Elevance Health. It's a powerful combination, and the foundation upon which we're creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve.
Carelon Medical Benefits Management is currently seeking a Board-Certified Sleep Specialist to participate in pre-authorization and quality improvement solutions for sleep studies and high-tech general medicine diagnostic imaging. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cardiology and sleep management requests using clinical guidelines and health plan medical policy.
Successful candidates will:
Determine medical necessity of requests using applicable clinical criteria, which may include Carelon Medical Benefits Management Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, and CMS Coverage Determinations, as applicable.
Perform physician-level case review of sleep studies, durable medical equipment, high-tech diagnostic imaging, surgical procedures and other solutions as yet to be developed.
Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site of service.
Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.
Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.
Actively participate in physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.
Actively participate in groups that develop, revise, and enhance clinical appropriateness guidelines
Perform first level provider appeals of coverage decisions.
Obtain additional state licensure based upon state regulations and health plan needs
Adhere to all AIM Specialty Health protocols, policies, and procedures
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification by American Board of Medical Specialties in Sleep Medicine
3-5 years of clinical practice experience past fellowship training is desirable
Demonstrated knowledge of current practice standards in your 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
Preferred interest in Sleep management utilization review
