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Medical Director, Medicare Markets

Location:

  • IL, Deerfield

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Description

Medical Director, Medicare Markets

Location: Remote, can live anywhere. Must be able to work Central Time Zone hours.  


Responsible for leading and ensuring the clinical integrity and efficient, compliant delivery of AIM clinical solutions to all clients with Medicare lines of business.

How you will make an impact:

  • Collaborates with business partners to develop new solutions for the provision of appropriate, safe and affordable whole person care.

  • Collaborates with other solution medical directors to ensure a holistic approach to benefit management.

  • Provides clinical expertise in sales planning and participates in the acquisition and retention of client business.

  • Collaborates with sales/client development management team and other solution medical directors and medical management teams to anticipate and address specific client concerns and requirements.

  • Supports the completion of RFIs and RFPs and other sales and client development activities as needed to support government programs membership and revenue growth.

  • Supports client implementations for government lines of business and is a key member of the team supporting the client’s clinical leadership both during and after implementations.

  • May conduct escalated peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.

  • Partners with regulatory/compliance and medical policy teams on interpretation of existing policies and clinical guidelines and develops or recommends new policies based on changes in the healthcare regulatory/legal arena.

  • Monitors competitor products and internal medical management capabilities and responds with recommendations for improvement in company models.

  • Monitors the clinical and financial performance of our solutions, in partnership with solution teams, clinical operations, and sales/client development.

  • Serves as a key clinical leader and resource for the clinical call center clinical teams and operations teams to ensure all aspects of program delivery meet necessary standards.

  • Uses data for predictive analysis and to help guide business decisions.

  • Identifies and develops opportunities for innovation to increase effectiveness and quality.

  • May provide oversight, direction, and guidance to Medical Director Associates.

  • Serves as a resource and subject matter expert consultant to other areas of the company.

  • May serve on company committees.

  • May represent the company to external entities and/or serve on external committees and provides guidance for clinical operational aspects of the program.

Minimum Requirements:

  • Requires 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).

  • Must possess an active unrestricted medical license to practice medicine or a health profession.

  • Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and 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.

Preferred Qualifications: 

  • Managed care knowledge, experience in health plan administration and/or accountable care organization medical management and value-based contracts strongly preferred.

  • Knowledge of Medicare regulatory environment, compliance standards, and National and Local Coverage Determination (NCD/LCD) hierarchies preferred.

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

  • If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions.

  • Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.

  • Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.


Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. 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 ability@icareerhelp.com for assistance.

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