Remote Medical Director - Utilization & Policy Lead

Elevance Health; Independence Township (OH); Hybrid; USD 180,000 - 240,000; Full time

Job summary

Elevance Health is seeking a Medical Director - Individual Segment to lead clinical policy development and utilization management initiatives. This role combines program leadership with hands-on review of medical necessity and benefit determinations across network requests.

You will guide clinical operations, collaborate with providers and internal teams, and contribute to cost-of-care improvements while supporting innovative health solutions.

Qualifications

• MD or DO with ABMS/AOA board certification.
• Active unrestricted medical license to practice.
• Must be located in the United States for utilization review.
• Minimum 10 years of clinical experience.
• Minimum 5 years healthcare experience for Health Solutions/Carelon.
• Additional state contract requirements may apply.

Responsibilities

• Lead clinical policy development and program implementation.
• Oversee utilization review and management.
• Review cases for medical necessity and benefit determinations.
• Evaluate in-network vs out-of-network requests.
• Represent the company to external entities and participate in committees.
• Identify opportunities for cost-of-care improvements.

Skills

Clinical policy development

Utilization management

Peer-to-peer reviews

Program management

Education

MD or DO with ABMS/AOA board cert

Job description

Elevance Health is seeking a Medical Director - Individual Segment to lead clinical policy development and utilization management initiatives. This role combines program leadership with hands-on review of medical necessity and benefit determinations across network requests.

You will guide clinical operations, collaborate with providers and internal teams, and contribute to cost-of-care improvements while supporting innovative health solutions.