Medical Director – Cardiology
| Company | Elevance Health |
|---|---|
| Location | Indianapolis, IN, USA, Houston, TX, USA, Washington, DC, USA, Miami, FL, USA, Chicago, IL, USA, Latham, NY, USA, New York, NY, USA, Atlanta, GA, USA |
| Salary | $205470.72 – $337559.04 |
| Type | Full-Time |
| Degrees | MD |
| Experience Level | Senior, Expert or higher |
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.
- Minimum of 1 year of experience with clinical case reviews for medical necessity. *The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only; Cardiology, Oncology, and Interventional Pain specialties.*
- Board certification in a medical specialty required.
Responsibilities
- Ensures timely completion of clinical case reviews for their board certified specialty.
- Makes physician to physician calls to gather medical appropriate information in order to make medical necessity determinations for services requested.
- Makes medical necessity determinations for grievance and appeals appropriate for their specialty.
- Ensures consistent use of company medical policies when making medical necessity decisions.
- Brings to their supervisors attention, any case review decisions that require Medical Director review or policy interpretation.
- Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well established evidenced based guidelines, state mandated policies, and CMS Coverage Determinations, as applicable.
- Perform physician-level case review of utilization requests for procedures and interventions listed above.
- Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging, and appropriate sites of service.
- Discuss clinically appropriate alternative treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
- Provide education regarding applicable clinical criteria.
Preferred Qualifications
- Board Certification in Cardiovascular Disease, Interventional Radiology or Vascular Surgery by the American Board of Internal Medicine or Surgery.
- 3-5 years of clinical practice experience past fellowship training is desirable.
- Demonstrated knowledge of current practice standards in Vascular surgery or Cardiology.