We are currently seeking a versatile Board Certified Physician to participate in pre-authorization reviews of high-tech diagnostic imaging, cardiac testing and sleep management services. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cardiology, sleep management, endoscopies and surgical site of care requests using clinical guidelines, state mandates, health plan medical policy and Medicare Coverage Determinations.

The Associate Medical Director, Sleep Medicine 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 Carelon Medical Benefits Management Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, and CMS Coverage Determinations, as applicable.

• Perform physician-level case review of sleep studies, durable medical equipment, high-tech diagnostic imaging, surgical procedures and other solutions as yet to be developed.

• Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site 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.

• Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.

• Actively participate in physician team meetings.

• Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.

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

• Perform first level provider appeals of coverage decisions.

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

• Adhere to all AIM Specialty Health 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. Board Certification by American Board of Medical Specialties in Sleep Medicine.

Preferred Skills, Capabilities, and Experiences:

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

• Demonstrated knowledge of current practice standards in your specialty.

• 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 Sleep management utilization review.

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.