Utilization Management Medical Director NC Medicaid

Anticipated End Date :

Position Title :

Utilization Management Medical Director - NC Medicaid

Job Description :

Utilization Management Medical Director- NC Medicaid

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. 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. Ideal candidate will live in North Carolina but not required . Alternate locations may be considered.

The Medical Director will be responsible for utilization review case management for North Carolina Medicaid. 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.

How you will make an impact :

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 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.

Serves 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.

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.

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).

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

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 filing a role required by a State agency.

Preferred Qualifications :

Family Medicine Internal Medicine or Ob / GYN board certifications preferred.

Job Level : Director Equivalent

Workshift :

1st Shift (United States of America)

Job Family : MED >

Licensed Physician / Doctor / Dentist

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 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.

Required Experience :

Director

Key Skills

EMR Systems,Post Residency Experience,Occupational Health Experience,Clinical Research,Managed Care,Primary Care Experience,Medical Management,Utilization Management,Clinical Development,Clinical Trials,Leadership Experience,Medicare

Employment Type : Full-Time

Experience : years

Vacancy : 1