Behavioral Health Medical Director-Psychiatrist Appeals at Elevance Health

Indianapolis, Indiana, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

MD or DO and Board certification approved by American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA), where applicable to duties
Active unrestricted medical license to practice medicine or a health profession
Located in a state or territory of the United States when conducting utilization review or appeals (not on US military base, vessel, or embassy)
Minimum of 10 years of clinical experience, or equivalent combination of education and experience
For Behavioral Health: minimum of 5 years of experience providing health care
Additional experience as required by State contracts or regulations if role required by a State agency
Preferred Skills, Capabilities and Experiences
Child and Adolescent experience
Utilization Management experience
Applied Behavior Analysis (ABA) experience
Active unrestricted medical license in California or ability to obtain upon hire

Responsibilities

Administer behavioral health medical services to ensure appropriate and cost-effective medical care
Develop and implement programs to improve quality, cost, and outcomes
Provide clinical consultation and serve as clinical/strategic advisor to enhance clinical operations
Identify cost of care opportunities
Support clinicians to ensure timely and consistent responses to members and providers
Provide guidance for clinical operational aspects of a program
Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers
Serve as a resource and consultant to other areas of the company
Represent the company to external entities and/or serve on internal/external committees; may chair company committees
Interpret medical policies and clinical guidelines; develop and propose new medical policies
Lead, develop, direct, and implement clinical and non-clinical activities impacting health care quality, cost, and outcomes
Identify and develop opportunities for innovation to increase effectiveness and quality
Provide oversight, direction, and guidance to Medical Director Associates
Work independently with oversight from immediate manager
Manage an entire clinical program and/or independently perform clinical reviews
Handle program management responsibilities including clinical policy development, quality/cost/outcomes improvement, program development/implementation, and overseeing clinical/non-clinical activities

Skills

Psychiatry

Behavioral Health

Medical Appeals

Peer-to-Peer Reviews

Clinical Guidelines

Medical Policy

Utilization Management

Clinical Operations

Quality Improvement

Cost Management

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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