Medical Director at Elevance Health responsible for the administration of healthcare services and improving quality outcomes. Ensuring efficient cost - effective medical care and supporting clinicians in their roles.
About the role
- Medical Director for Quantum Health serving clients and navigating healthcare complexities. Focused on clinical reviews and improving member outcomes in a hybrid role.
Responsibilities
- Serves as a key clinical resource for staff
- Establishes criteria and protocols for standard medical treatment inquiries and renders determinations on requests for healthcare services and/or treatment
- Conducts daily review of individual cases and has necessary case level conversations as requested
- Provides clear and concise documented medical review determinations and support on requested reviews within the established time frames
- Provides clinical and nurse consultations
- Identifies opportunities to implement best practices approaches and introduce innovations to provide improved outcomes
- Performs utilization review and case management support on complex members
- Provides support over the phone, through messaging and video to support chronic disease management
- Offers peer-to-peer discussions regarding determinations as necessary
- Serves as a medical liaison to physicians, hospitals and insurance carriers
- Provides determination on appeals for cases where they did not make the initial determination
- Utilizes data resources and tools that helps our team provide personalized care to our clients
- Evaluates and interprets data. Identifies areas for improvement with a focus on interventions to improve client outcomes
- All other duties as assigned
Requirements
- Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO)
- Board certification in primary specialty required
- Minimum of five (5) years of progressively responsible clinical practice experience
- Minimum of two (2) years of physician clinical review experience, preferably within a commercial health plan or utilization management environment
- Strong written and verbal communication skills, including clear clinical documentation
- Collaborative, team-oriented mindset with the ability to work effectively across disciplines
- Knowledge of the U.S. healthcare delivery system
- Demonstrated knowledge of utilization management principles and evidence-based criteria (e.g., InterQual)
- Commitment to protecting company and member data by adhering to organizational ethics, privacy, and security policies
- Hold a current, valid, and unrestricted license to practice medicine that is recognized in the relevant jurisdiction(s)
- Ability to obtain and maintain multistate licensure as required
Benefits
- Health, vision and dental insurance
- Life insurance
- Legal and identity protection
- Adoption assistance
- EAP
- Teladoc services
- 401(k) plan with up to 4% employer match
- Paid Time Off (PTO)
- 7 paid holidays
- Parental leave
- Volunteer days
- Paid sabbaticals
- Tuition reimbursement up to $5,250 annually
- Certification/continuing education reimbursement
- Discounted higher education partnerships
- Paid trainings and leadership development
- Casual dress code
- Full-service dining
- Free snacks and drinks
- Complimentary 24/7 fitness center with group classes
- Outdoor walking paths
- Game room
- Notary and dry-cleaning services
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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