Job Information
Elevance Health Plan Performance Medical Director – Maine and New Hampshire Markets in SOUTH PORTLAND, Maine
Plan Performance Medical Director – Maine and New Hampshire Markets
Location: This is a hybrid position, be expected to go to the office at least once a week plus in person external customer meetings 1-2 times a month.
Build the Possibilities. Make an extraordinary impact.
Responsible for serving as the lead clinician for a plan. Responsible for the administration of medical services for company health plan including the overall medical policies or clinical guidelines of the plan to ensure the appropriate and most cost-effective medical care is received. Drives direction of the plan related to cost of care and other plan directives. Works with the market plan president during meetings with State Regulator.
How you will make an impact:
Supports the Medical Management staff 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 with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Interprets existing policies or clinical guidelines and develops new policies based on changes in the healthcare or medical arena.
Leads, develops, directs, and implements clinical and non-clinical activities that impact efficient and effective care.
Identifies and develops opportunities for innovation to increase effectiveness and quality.
Provides expertise, captures, and shares best practices across regions to other medical directors.
May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.
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).
Requires active unrestricted medical license to practice medicine or a health profession in NH and ME.
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:
Health Plan experience strongly preferred.
Residency within ME or NH strongly preferred.