Director of Medical Operations
DescriptionSHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
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.
Responsible for the day to day medical management operations along with local quality and improvement initiatives for the State Health Plan.
Primary duties may include, but are not limited to:
- Interprets existing policies 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 health care quality cost and outcomes. S
- 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 as needed.
- Serves on company committees and may be required to represent Anthem to external entities and/or serve on external committees, conduct peer clinical and/or appeal case reviews and peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations.
- Provides guidance for clinical operational aspects of the program and supports the medical management staff ensuring timely and consistent responses to members and providers.
- Hires, trains, coaches, counsels, and evaluates performance of direct reports.
- 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.
- 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.
- Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.