Appeals Medical Director - Medicare

About the role

The Appeals Medical Director 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.

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 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.
• Develops and proposes 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.

Requirements

• MD or DO and 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 any combination of education and experience, which would provide an equivalent background.
• Primary Care specialties preferred.
• Utilization Management or Appeals experience preferred.

Qualifications

• Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Primary Care specialties preferred.
• Utilization Management or Appeals experience preferred.

Benefits

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and a 401(k) match. Additional benefits include medical, dental, vision, short and long term disability benefits, life insurance, wellness programs, and financial education resources. The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

Pay

Location(s): Illinois, Massachusetts, Maryland, New Jersey, New York, and Columbus, OH. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Schedule

Location(s): Illinois, Massachusetts, Maryland, New Jersey, New York, and Columbus, OH. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).