Appeals Medical Director – Medicare

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.

About the Role

The Appeals Medical Director is responsible for the appeal reviews for physical health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing programs to improve quality, cost, and outcomes. May provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations. May identify cost of care opportunities.

How You Make An Impact

• Serves 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.
• Might be required to represent the company to external entities and/or serve on internal and/or external committees.
• Might 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.

Minimum Requirements

• 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).
• Active unrestricted medical license to practice medicine or a health profession.
• 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

• Primary Care specialties preferred.
• Utilization Management or Appeals experience preferred.

Pay

Location(s): Illinois, Massachusetts, Maryland, New Jersey, New York, and Columbus, OH.
The salary* range for this specific position is $247,840.00 to $446,112.00.

Benefits

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).

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.

Elevance Health

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 may contact elevancehealthjobssupport@elevancehealth.com for assistance.