Clipped from: https://www.learn4good.com/jobs/online_remote/healthcare/2035811060/e/
Position: Medical Director- Utilization Review Management for Medicaid
Position
Title:
Medical Director
– Utilization Review Management for Medicaid
Job Description:
Medical Director
Location:
Remote/Work from Home position. Strongly prefer candidates to live in North Carolina.
Must be able to work eastern time zone hours.
Build the Possibilities. Make an extraordinary impact.
Responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities. May serve as a resource to staff including Medical Director Associates.
May be responsible for an entire clinical program.
How you will make an impact:
- Supports clinicians to ensure timely and consistent responses to members and providers.
- Provides guidance for clinical operational aspects of a program.
- Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
- May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
- Serves as a resource and consultant to other areas of the company.
- May be required to represent the company to external entities and/or serve on internal and/or external committees.
- May chair company committees.
- Interprets medical policies and clinical guidelines.
- May develop and propose new medical policies based on changes in healthcare.
- Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
- Identifies and develops opportunities for innovation to increase effectiveness and quality.
Minimum Requirements:
- Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS), American Osteopathic Association (AOA) or National Board of Physicians and Surgeons (NBPAS).
- Must possess an active unrestricted medical license to practice medicine or a health profession.
- Must possess or have the ability to obtain a North Carlina medical license.
- Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
- Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.
- If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position’ work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.
- Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.
Preferred
Qualifications:
- Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.
- Internal Medicine, Family Medicine, or OB/GYN specialties preferred. Other specialties will be considered.
Job Level:
Director Equivalent
Workshift:
Job Family:
MED >
Licensed Physician/Doctor/Dentist
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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate.
Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at …