Remote Medical Director - Utilization & Policy Lead

Elevance Health (Anthem); Cincinnati (OH); On-site; USD 180,000 - 260,000; Full time

Job summary

Elevance Health seeks a Medical Director - Individual Segment to lead clinical policy development, program management, and utilization review for member care. You will oversee medical necessity reviews, benefit determinations, and in-network decisions, collaborating with clinicians to improve outcomes and cost-of-care initiatives.

The role requires an MD or DO with board certification, an active medical license, and extensive clinical experience.

Qualifications

• Requires MD or DO and ABMS or AOA board certification.
• Active unrestricted medical license to practice medicine.
• Must be located in the United States for utilization review or appeals.
• Minimum of 10 years of clinical experience; 5+ years for Health Solutions/Carelon.

Responsibilities

• 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 physicians to discuss determinations.
• May conduct peer-to-peer clinical appeal case reviews with providers.
• Represents the company to external entities and serving on committees.
• Interprets medical policies and guidelines and proposes new policies.

Skills

Clinical policy development

Program management

Utilization review

Education

MD or DO

ABMS or AOA board certification

Job description

Elevance Health seeks a Medical Director - Individual Segment to lead clinical policy development, program management, and utilization review for member care. You will oversee medical necessity reviews, benefit determinations, and in-network decisions, collaborating with clinicians to improve outcomes and cost-of-care initiatives.

The role requires an MD or DO with board certification, an active medical license, and extensive clinical experience.