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. Any board certification by the American Board of Medical Specialties - preference for 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 $86.10/hr - $135.02/hr
Locations: California and Illinois
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.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
