Carelon Medical Benefits Management is currently seeking a Board-Certified Surgeon (or other surgical subspecialties beyond general surgery) to participate in pre-authorization and quality improvement solutions for a wide range of surgical procedures. Medical Directors determine the medical necessity of requests using clinical appropriateness guidelines.

The Associate Medical Director, Clinical Operations (Surgery) is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers.

Location: Remote. The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

How you will make an impact:

• Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, state mandated policies, and CMS Coverage Determinations, as applicable.

• Perform physician-level case review of utilization requests involving radiology imaging requests, endoscopies, surgical procedures and other codes to be determined.

• Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging, and appropriate sites of service.

  • Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.

  • Provide education regarding applicable clinical criteria.

• Perform first level provider appeals of coverage decisions.

• Demonstrate and maintain knowledge of applicable clinical criteria and relevant Carelon Medical Benefits Management policies pertaining to utilization review.

• Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to surgical services and procedures.

• Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate surgical diagnoses, treatments, and management.

• Actively participate in physician team meetings.

• Actively participate in groups that develop, revise, and enhance clinical appropriateness guidelines.

• Obtain additional state licensure based upon state regulations and health plan needs.

• Adhere to all Carelon Medical Benefits Management protocols, policies, and procedures.

Minimum Requirements:

• Requires an MD and Board certification in a medical specialty required. Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state. American Board of Medical Specialties board certification in General Surgery or other primary surgical specialties such as ENT, Plastic Surgery, Vascular Surgery, Cardio-thoracic, Trauma or Transplant surgical specialties.

Preferred Skills, Capabilities, and Experiences:

• 3-5 years of clinical practice experience past fellowship training is desirable

• Demonstrated knowledge of current practice standards in surgical care

• Strong oral communication and interpersonal skills

• Computer literacy with the ability to learn new applications

• Strong analytical skills

• Ability to multi-task

• Ability to work both independently and in a team environment

• Ability to work in a dynamic, fast-paced environment

• Preferred interest in Surgical utilization review

• Strong analytical skills

• Ability to multi-task

• Ability to work both independently and in a team environment

• Ability to work in a dynamic, fast-paced environment 

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For candidates working in person or remotely in the below locations, the salary* range for this specific position is $97.84/hr - $135.02/hr

Locations:  California

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). 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.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.