Medical Director - Individual Segment

Elevance Health; Durham (NC); Hybrid; USD 190,000 - 270,000; Full time

Benefits offered by this job

Hybrid work environment

Market-competitive rewards

Job summary

Elevance Health seeks a Medical Director for the Individual Segment. The role allows virtual full-time work with required in-person training, promoting flexibility and autonomy.

The candidate must be within a reasonable commuting distance or eligible for accommodations; alternate locations may be considered. The Medical Director will lead program management, clinical policy development, and utilization management, reviewing care requests for medical necessity and contributing to cost-of-care

Qualifications

• MD or DO with board certification in a relevant specialty (ABMS or AOA).
• Active unrestricted medical license to practice medicine or health profession.
• Must be located within reasonable commuting distance or eligible for accommodation.
• Minimum of 10 years of clinical experience, or equivalent.
• Health Solutions/Carelon: minimum of 5 years healthcare experience.

Responsibilities

• Develop and oversee clinical policy development and program implementation.
• Oversee utilization review/management and assess medical necessity.
• Conduct peer-to-peer clinical reviews and discuss determinations with providers.
• Represent the company to external entities and/or serve on committees.
• Lead clinical and non-clinical activities impacting care quality and cost.

Skills

Leadership

Clinical policy development

Utilization management

Peer-to-peer reviews

Stakeholder collaboration

Education

MD or DO

ABMS/AOA board certification

Active unrestricted medical license

Job description

Medical Director - Individual Segment

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Alternate locations may be considered.

The Medical Director will have program management responsibilities including clinical policy development, program development/implementation, and overseeing clinical/non-clinical activities. Will also be responsible for utilization review/management. The role focuses on reviewing cases for medical necessity, making benefit determinations, evaluating in-network and out-of-network care requests, and supporting utilization management functions. Team members may also contribute to process improvement and cost-of-care initiatives, although participation in these projects is optional.

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) or American Osteopathic Association (AOA).

• Must possess an active unrestricted medical license to practice medicine or a health profession.

• 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 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.

• Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Preferred Qualifications:

• Experience in managed care experience strongly preferred.

• 1-2 years utilization management review experience preferred.

• Clinical experience working in internal medicine or family practice strongly preferred.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/).