Associate Medical Director - Genetic Testing Utilization Review
About the position
The Clinical Operations Associate Medical Director at Carelon Health plays a pivotal role in supporting the medical management staff to ensure timely and consistent medical decisions for members and providers. This position is integral to the medical review process, ensuring that clinical case reviews are completed promptly and accurately. The Associate Medical Director will be responsible for making physician-to-physician calls to gather necessary medical information, which is crucial for making informed medical necessity determinations for requested services. This role also involves making medical necessity determinations for grievances and appeals relevant to their specialty, ensuring that all decisions are consistent with established medical policies. In addition to these responsibilities, the Associate Medical Director will be expected to bring any case review decisions that require further review or policy interpretation to the attention of their supervisors. This position requires a strong understanding of medical policies and the ability to apply them consistently in decision-making processes. The ideal candidate will have a background in a medical specialty and will be committed to upholding the standards of care and ensuring that members receive the appropriate medical services they need. The role is designed for a candidate who is not only knowledgeable in their specialty but also possesses strong communication skills to effectively interact with other healthcare professionals. The position offers the flexibility of working from home while requiring the candidate to reside within 50 miles of an Elevance Health PulsePoint location. The work schedule is Monday through Friday, from 9 AM to 5:30 PM, in the candidate's local time zone, allowing for a balanced work-life integration.
Responsibilities
Ensure timely completion of clinical case reviews for their board certified specialty.
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Make physician to physician calls to gather medically appropriate information for medical necessity determinations.
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Make medical necessity determinations for grievances and appeals appropriate for their specialty.
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Ensure consistent use of medical policies when making medical necessity decisions.
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Bring to supervisors' attention any case review decisions that require Medical Director review or policy interpretation.
Requirements
Requires an MD and Board certification in a medical specialty.
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Primary Care/Internal Medicine Board Certification preferred.
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Knowledge/Experience in Genetic Testing preferred but not required.
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Compact License or residing in a Compact State strongly preferred.
Nice-to-haves
Benefits
Comprehensive benefits package
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Incentive and recognition programs
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Equity stock purchase
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401k contribution
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Paid holidays
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Paid Time Off
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Medical, dental, vision benefits
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Short and long term disability benefits
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Life insurance
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Wellness programs
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Financial education resources
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