[Hiring] Specialist Medical Director - Cardiology @Elevance Health

Role Description

The Clinical Operations Medical Director is responsible for performing pre-authorizations and providing quality improvement solutions involving cardiovascular procedures and requests for oncologic treatment (medical or radiation) including future expansions.

• Determines the medical necessity of requests using clinical criteria.
• Performs physician-level case review of cardiovascular or oncologic utilization requests.
• Conducts peer-to-peer consultation 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.
• Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options.
• Performs first level provider appeals for coverage decisions.
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management related to these specialties.
• Participates in physician team meetings.
• Participates in groups that develop, revise, and enhance clinical appropriateness guidelines.

Qualifications

• Requires MD and/or DO, completion of training in Cardiology, Oncology, or related board certification by either the American Board of Medical Specialties or the American Osteopathic Association Specialties.
• Requires a current, valid, active and unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s).
• Requires a minimum of 5 years of clinical experience.

Requirements

• Experience with utilization management, especially with CMS guidelines preferred.
• Board certification in Cardiology strongly preferred.

Benefits

• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, and vision benefits.
• Short and long-term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.