Sign-on Bonus: $10,000

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.   

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

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 medical 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 supervisors 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 Requirements:

• Requires an MD and 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.

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.