Medical Director-Appeals (Primary Care-IM or FM)

About the position

The Medical Director-Appeals role at Elevance Health is a hybrid position focused on overseeing appeal reviews for physical health medical services. The primary responsibility is to ensure that members receive appropriate and cost-effective medical care. The role involves developing and implementing programs aimed at improving quality, cost, and outcomes, as well as providing clinical consultation and serving as a strategic advisor to enhance clinical operations. The Medical Director may also identify cost of care opportunities and serve as a resource for staff, including Medical Director Associates.

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

Requirements
? MD or DO with Board certification approved by ABMS or AOA.
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? Active unrestricted medical license to practice medicine or a health profession.
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? Minimum of 10 years of clinical experience or equivalent education and experience.
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? For Health Solutions and Carelon organizations, minimum of 5 years of experience providing healthcare is required.

Nice-to-haves
? Board certification in Internal or Family medicine strongly preferred.
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? Florida medical license or the ability to obtain once hired strongly preferred.

Benefits
? Merit increases
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? Paid holidays
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? Paid Time Off
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? Incentive bonus programs
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? Medical, dental, and vision benefits
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? Short and long term disability benefits
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? 401(k) with matching
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? Stock purchase plan
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? Life insurance
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? Wellness programs
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? Financial education resources

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