Medical Director-Cardiology Appeals

Medical Director-Cardiology Appeals

Location : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered. Please note that per our policy on hybrid / virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Medical Director-Cardiology Appeals is responsible for the review of appeals for physical health medical services, to ensure the appropriate and most cost-effective medical care is received. May be responsible for developing and implementing 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. May be responsible for an entire clinical program.

How you will make an impact :

Complete appeal reviews in your specialty daily to ensure timely and consistent responses to members and providers.

Provide guidance for clinical operational aspects of a program.

May conduct peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations

Serve as a resource and consultant to other areas of the company.

May be required to represent the company to external entities and / or serve on internal and / or external committees.

May chair company committees.

Interpret medical policies and clinical guidelines.

May lead, develop, direct, and implement clinical and non-clinical activities that impact health care quality cost and outcomes.

Identify and develop opportunities for innovation to increase effectiveness and quality.

Work independently with oversight from immediate manager.

May be responsible for an entire clinical program and / or independently perform clinical reviews.

Minimum Qualifications

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).

Board certification in Cardiology.

Must possess an active unrestricted medical license to practice medicine or a health profession. 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.

For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required.

Additional experience may be required by State contracts or regulations if the Medical Director is filling a role required by a State agency.

For URAC accredited areas, the following professional competencies apply : Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and / or government clearances, segregation of duties, principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient / member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.