Medical Director-Appeals (Primary Care-IM or FM)

About the position The Medical Director-Appeals role at Elevance Health is a hybrid position focused on overseeing appeal reviews for physical health medical services. The primary responsibility is to ensure that members receive appropriate and cost-effective medical care. The role involves developing and implementing programs aimed at improving quality, cost, and outcomes, as well as providing clinical consultation and serving as a strategic advisor to enhance clinical operations. The Medical Director may also identify cost of care opportunities and serve as a resource for staff, including Medical Director Associates. Responsibilities • Conduct appeal reviews for physical health medical services. , • Support clinicians to ensure timely and consistent responses to members and providers. , • Provide guidance for clinical operational aspects of a program. , • Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers. , • Serve as a resource and consultant to other areas of the company. , • Represent the company to external entities and/or serve on internal and/or external committees. , • Chair company committees as needed. , • Interpret medical policies and clinical guidelines. , • Develop and propose new medical policies based on changes in healthcare. , • Lead, develop, direct, and implement clinical and non-clinical activities that impact healthcare quality, cost, and outcomes. , • Identify and develop opportunities for innovation to increase effectiveness and quality. Requirements • MD or DO with Board certification approved by ABMS or AOA. , • Active unrestricted medical license to practice medicine or a health profession. , • Minimum of 10 years of clinical experience or equivalent education and experience. , • For Health Solutions and Carelon organizations, minimum of 5 years of experience providing healthcare is required. Nice-to-haves • Board certification in Internal or Family medicine strongly preferred. , • Florida medical license or the ability to obtain once hired strongly preferred. Benefits • Merit increases , • Paid holidays , • Paid Time Off , • Incentive bonus programs , • Medical, dental, and vision benefits , • Short and long term disability benefits , • 401(k) with matching , • Stock purchase plan , • Life insurance , • Wellness programs , • Financial education resources Apply Job!