Job Overview
The Medical Director- Florida Medicare Plans role at Elevance Health supports Florida Medicare plans including Simply Healthcare Plans, Healthsun Plans, Freedom Health, and Optimum Healthcare Plans. The incumbent is responsible for utilization review case management in these markets, developing and implementing programs to improve quality, cost, and outcomes, and serving as a clinical/strategic advisor.
Location
This role enables associates to work virtually full-time, with required in-person training sessions. Candidates must reside in Florida near our Miami or Tampa locations. Hybrid policy applies for those not within a reasonable commuting distance.
Responsibilities
- Supports clinicians to ensure timely and consistent responses to members and providers.
- Provides guidance for clinical operational aspects of a program.
- Performs utilization management reviews to determine medical necessity and appropriateness of care using nationally recognized criteria.
- Collaborates with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
- Provides peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.
- Ensures timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards.
- Serves as a resource and consultant to other areas of the company.
- Might be required to represent the company to external entities and/or serve on internal and/or external committees.
- Might chair company committees.
- Interprets medical policies and clinical guidelines.
- Might 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.
- Expectations include weekend and holiday coverage during assigned rotations to support continuity of UM operations and ensure timely case processing.
Minimum Requirements
- MD or DO with Board certification from American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) as applicable.
- Active unrestricted medical license to practice medicine in Florida.
- Located within the United States; cannot be located on a U.S. military base, vessel, or embassy.
- Minimum of 10 years of clinical experience or equivalent combination of education and experience.
- For Health Solutions and Carelon organizations, minimum of 5 years of experience providing health care (additional experience may be required by State contracts or regulations).
Preferred Qualifications
- Bilingual – Spanish speaking preferred.
- Utilization Management case review experience strongly preferred.
- Previous experience working for a health plan or managed care organization preferred.
- Previous Medicare experience preferred.
- Internal/Family Medicine or other adult medicine training preferred.
COVID‑19 Vaccination Policy
All new candidates in certain patient/member‑facing roles must be vaccinated against COVID‑19 and Influenza. If not vaccinated, the offer will be rescinded unless an acceptable explanation is provided.
EEO Statement
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender identity, gender expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other protected class. Qualified applicants with arrest or conviction records will be considered in accordance with all applicable laws.
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