Utilization Management Medical Director- NC Medicaid

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:

* Pediatrics board certification preferred.

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…