Home Health Clinical Operations Medical Director - MD/DO - UM
DescriptionSHIFT: Day Job
Be part of an extraordinary team
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
A proud member of the Anthem Inc family of companies, myNEXUS is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.
This position is part of our hybrid workforce model but has the opportunity for full time work from home.
Responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers regarding Home Health benefits through Utilization Managment guidlines.
Primary duties may include, but are not limited to:
- 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.
Required Skills and Abilities:
- Requires an MD/DO and minimum of 1 year of experience with clinical case reviews for medical necessity.
- 3, or more, years of clinical expereince post residency.
- Board certification in a medical specialty required. Internal Medicine, Geriatrics, Family Medicine, or Physiatry oard certification preferred.
- Expereice in Home Health clincial or UM environment strongly preferred.
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 Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. 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 age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. 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.