Medical Director- Florida Medicare Plans at Elevance Health

Miami, Florida, 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 Insurance, MedicareIndustries

Requirements

MD or DO degree
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 in Florida
Must reside in Florida near Miami or Tampa locations (per hybrid/virtual work policy; candidates not within reasonable commuting distance not considered unless accommodation granted)
Must be 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 Health Solutions and Carelon (including behavioral health), minimum 5 years providing health care (additional experience may be required by state contracts/regulations)

Responsibilities

Support clinicians to ensure timely and consistent responses to members and providers
Provide guidance for clinical operational aspects of a program
Perform utilization management reviews to determine medical necessity and appropriateness of care using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines)
Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays
Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives
Ensure timely and accurate completion of reviews in compliance with state/federal regulations, NCQA, and company standards
Serve as a resource and consultant to other areas of the company
May represent the company to external entities and/or serve on internal/external committees; may chair company committees
Interpret medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
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
Support Florida Medicare plans (Simply Healthcare Plans, Healthsun Plans, Freedom Health, Optimum Healthcare Plans) with utilization review case management
May develop and implement 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
May serve as a resource to staff including Medical Director Associates
Provide weekend and holiday coverage during assigned rotations to support UM operations continuity and timely case processing

Skills

Utilization Management

Utilization Review

Case Management

MCG

InterQual

CMS Guidelines

Medical Necessity Review

Peer-to-Peer Discussions

Clinical Operations

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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