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Plan Performance Medical Director

Elevance Health
Published
June 7, 2024
Location
St Louis, MO
Category
Other  
Job Type
Work Setting
Remote / Home-based, In-office

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.

The Plan Performance Director is responsible for serving as the lead clinician for a plan. Responsible for the administration of medical services for company health plan including the overall medical policies or clinical guidelines of the plan to ensure the appropriate and most cost-effective medical care is received. Drives direction of the plan related to cost of care and other plan directives. Works with the market plan president during meetings with State Regulator.

Roles and Responsibilities

  • Supports the Medical Management staff 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.
  • Interprets existing policies or clinical guidelines and develops new policies based on changes in the healthcare or medical arena.
  • Leads, develops, directs and implements clinical and non-clinical activities that impact efficient and effective care.
  • Identifies and develops opportunities for innovation to increase effectiveness and quality.
  • Provides expertise, captures and shares best practices across regions to other medical directors.
  • May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.

Education and Experience

  • 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).
  • Requires active unrestricted medical license to practice medicine or a health profession.
  • Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
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