Medical Director leading clinical initiatives and supporting healthcare policies in UK insurance. Collaborating with industry leaders and managing healthcare practices to ensure quality care.
About the role
- Medical Director overseeing Florida Medicare Plans and utilization management for Elevance Health. Collaborating with clinicians for quality care and operational guidance in Florida.
Responsibilities
- Support clinicians to ensure timely and consistent responses to members and providers
- Provide guidance for clinical operational aspects of a program
- Perform utilization management reviews to determine medical necessity and appropriateness of care
- Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays
- Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives
- Ensure timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards
- Serve as a resource and consultant to other areas of the company
- May represent the company to external entities and/or serve on internal and/or external committees
- Interpret medical policies and clinical guidelines
- May develop and propose new medical policies based on changes in healthcare
- Lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality cost and outcomes
- Identify and develop opportunities for innovation to increase effectiveness and quality
- Expectation for this role also includes weekend and holiday coverage during assigned weekend rotations
Requirements
- Requires MD or DO and Board certification approved by one of the following certifying boards is required
- Must possess an active unrestricted medical license to practice medicine or a health profession in Florida
- Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background
- For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required
- Bilingual- Spanish speaking preferred
- Utilization Management case review experience strongly preferred
- Previous experience working for a health plan or managed care organization preferred
- Previous Medicare experience preferred
- Internal/Family Medicine or other adult medicine training preferred
Benefits
- Health insurance
- 401(k) +match
- Paid Time Off
- Paid holidays
- Long term disability benefits
- Short term disability benefits
- Life insurance
- Wellness programs
- Financial education resources
- Incentive bonus programs
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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