Description
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for contract workers (via BCforward) who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
Responsible for ensuring the company meets their product standards and commitments to customers and for ensuring physician utilization of company protocols, guidelines and policies/procedures.
Primary duties may include, but are not limited to
- Maintains the quality and timeliness of peer clinical and/or appeal case review decision making across all product lines.
- Consults with team members to ensure consistency, and superior customer service.
- Improves service to clients and unit productivity through continuous enhancement of whole team clinical knowledge and enhanced understanding of company systems, products, programs, procedures and customers.
- Interprets existing policies and develops new policies based on changes in the healthcare or medical arena.
- Supports the Medical Management staff ensuring timely and consistent responses to members and providers.
- Identifies and develops opportunities for innovation to increase effectiveness and quality.
- 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 external committees.
- Conduct peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations and provides guidance for clinical operational aspects of the program.
Requirements
- Requires M.D. or D.O.; Board certification approved by the American Board of Medical Specialties required, must possess an active unrestricted medical license to practice medicine or a health profession.
- The candidate should be Board certified in Family Medicine or Emergency Medicine.
- 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.
- 5 years clinical experience ; or any combination of education and experience, which would provide an equivalent background.
