Plan Performance Medical Director 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 degree
Board certification approved by the 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
Must be located in a state or territory of the United States when conducting utilization review or appeals consideration (cannot be on a US military base, vessel, or embassy)
Minimum of 10 years of clinical experience, or equivalent combination of education and experience
Strong oral, written, and interpersonal communication skills
Problem-solving skills
Facilitation skills
Analytical skills
Ability to travel to worksite and other locations as necessary

Responsibilities

Oversee the administration of medical services for individual ACA health plans across 17 states
Manage overall medical policies and clinical guidelines to ensure appropriate and cost-effective care
Lead initiatives to direct the plan on cost of care and other strategic directives
Collaborate with market plan presidents during meetings with state regulators
Support Medical Management staff to ensure timely and consistent responses to members and providers
Provide guidance for clinical operational aspects of programs
Conduct peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations and patients’ office visits
Conduct peer-to-peer clinical appeal case reviews with attending physicians or ordering providers
Interpret existing policies or clinical guidelines and develop new policies based on changes in the healthcare or medical arena
Lead, develop, direct, and implement clinical and non-clinical activities impacting efficient and effective care
Identify and develop opportunities for innovation to increase effectiveness and quality
Provide expertise, capture, and share best practices across regions to other medical directors
Chair or serve on company committees, represent the company to external entities, and/or serve on external committees

Skills

Medical Management

Clinical Guidelines

Peer-to-Peer Reviews

Healthcare Policy

Cost of Care Management

Regulatory Collaboration

ACA Health Plans

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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