Utilization Management Medical Director - NC Medicaid at Elevance Health

Durham, North Carolina, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, Managed CareIndustries

Requirements

MD or DO and 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 in North Carolina
Must be located in a state or territory of the United States when conducting utilization review or appeals (unless allowed by law/regulation; cannot be 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 organizations (including behavioral health), minimum of 5 years of experience providing health care (additional experience may be required by State contracts or regulations)

Responsibilities

Responsible for utilization review case management for North Carolina Medicaid
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
Supports clinicians to ensure timely and consistent responses to members and providers
Provides guidance for clinical operational aspects of a program
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations and patients’ office visits
May conduct peer-to-peer clinical appeal case reviews with attending physicians or ordering providers
Serves 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
Interprets medical policies and clinical guidelines
May develop and propose new medical policies based on changes in healthcare
Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality, cost, and outcomes
Identifies and develops opportunities for innovation to increase effectiveness and quality

Skills

Utilization Review

Case Management

Medicaid

Peer-to-Peer Review

Clinical Consultation

Quality Improvement

Cost Management

Medical Director

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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