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Medical Director – Florida Medicare, Part-Time
Elevance Health. Perform utilization management and medical necessity clinical reviews of inpatient and outpatient authorizations .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization management and medical necessity reviews, applying MCG, InterQual, and CMS guidelines. Proven ability to lead clinical initiatives, collaborate with healthcare professionals, and ensure compliance with state and federal regulations.
Highest-signal resume keywords
MD Or DOBoard CertificationActive Unrestricted Medical License10 Years Clinical ExperienceMedicare Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementMedical Necessity ReviewsClinical Guidelines InterpretationPeer Review ParticipationQuality Improvement InitiativesCost-Of-Care InitiativesClinical Operational GuidanceAppeals Medical Necessity ReviewsCommittee LeadershipInnovation Development
Soft Skills
CollaborationCommunicationLeadershipConsultationProblem-Solving
Certifications & Qualifications
Board Certification Approved By ABMS Or AOACOVID-19 VaccinationInfluenza Vaccination
Industry Keywords
NCQA ComplianceHealthcare QualityInpatient AuthorizationOutpatient AuthorizationClinical ExperienceInternal MedicineFamily MedicinePeer-To-Peer Clinical DiscussionsState RegulationsHealthcare Changes
About the role
Key responsibilities & impact- Perform utilization management and medical necessity clinical reviews of inpatient and outpatient authorizations
- Conduct appeals medical necessity reviews
- Participate in peer-to-peer clinical discussions with treating physicians
- Participate in peer review, credentialing, quality, and other assigned committees
- Support clinicians in providing timely and consistent responses to members and providers
- Provide guidance for clinical operational aspects of programs
- Apply MCG, InterQual, CMS guidelines, and other nationally recognized criteria
- Collaborate with UM nurses and case managers on admissions, procedures, and continued stays
- Complete reviews accurately and on time in compliance with state and federal regulations, NCQA, and company standards
- Serve as a resource and consultant to other company areas
- Represent the company to external entities and serve on internal or external committees as required
- Chair company committees as needed
- Interpret medical policies and clinical guidelines
- Develop and propose new medical policies in response to healthcare changes
- Lead, develop, direct, and implement clinical and non-clinical activities affecting healthcare quality, cost, and outcomes
- Identify and develop innovation opportunities to increase effectiveness and quality
- Participate in weekend on-call coverage and holiday coverage during assigned rotations
- Lead assigned cost-of-care initiatives and projects
Requirements
What you’ll need- MD or DO required
- Board certification approved by ABMS or AOA required, where applicable to duties performed
- Active unrestricted medical license to practice medicine or a health profession in Florida required
- Must be located in a state or territory of the United States when conducting utilization review or appeals consideration, unless expressly allowed by law or regulation
- Cannot be located on a US military base, vessel, or embassy when conducting utilization review or appeals consideration
- Minimum of 10 years of clinical experience, or an equivalent combination of education and experience
- For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care is required
- Additional experience may be required by state contracts or regulations
- Previous Medicare experience preferred
- Internal/Family Medicine or other adult medicine training preferred
- Weekend and holiday coverage during assigned rotations
- Ability to work within Medicare turnaround-time compliance standards
- COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided
Benefits
Comp & perks- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual work flexibility
- Professional and personal growth opportunities