Clinical Operations Medical Director

Elevance Health Clinical Operations Medical Director

Location:

Remote. The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.The

Clinical Operations Medical Director

is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers. In this role, you will participate in pre-authorization and quality improvement solutions for both specialized cardiology and vascular surgery. This includes but is not limited to cardiac procedures such as coronary angiography, percutaneous coronary interventions, implanted cardiac devices, electrophysiology procedures and arterial/venous endovascular interventions.How you will make an impact:Ensures timely completion of clinical case reviews for their board certified specialty.Makes physician to physician calls to gather medically appropriate information in order to make medical necessity determinations for services requested.Makes medical necessity determinations for grievance and appeals appropriate for their specialty.Ensures consistent use of company medical policies when making medical necessity decisions.Brings to their supervisor's attention any case review decisions that require Medical Director review or policy interpretation.Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well-established evidenced based guidelines, state mandated policies, and CMS Coverage Determinations, as applicable.Perform physician-level case review of utilization requests for procedures and interventions listed above.Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging, and appropriate sites 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.Minimum Qualifications:Requires an MD and a minimum of 1 year of experience with clinical case reviews for medical necessity. The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only: Cardiology, Oncology, and Interventional Pain specialties.Board certification in a medical specialty required.Preferred Skills, Capabilities, and Experiences:Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.Board Certification in Cardiovascular Disease, Interventional Radiology or Vascular Surgery by the American Board of Internal Medicine or Surgery.3-5 years of clinical practice experience past fellowship training is desirable.Demonstrated knowledge of current practice standards in Vascular surgery or Cardiology.Job Level:

Non-Management Non-ExemptWorkshift:

1st Shift (United States of America)Job Family:

MED > Licensed Physician/Doctor/Dentist

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