Clin Ops Assoc Medical Dir-OS (US)
Elevance Health

The use of this job is limited to the Carelon Medical Benefits Management business unit. If you believe this to be the best match for your position, please consult with your Human Resources partner prior to using this job (HRBP should work with Compensation).

Responsible for performing pre-authorizations and providing quality improvement solutions for musculoskeletal procedures involving the joints and high-tech diagnostic imaging. Primary duties may include, but are not limited to: Determines the medical necessity of requests using clinical criteria. Performs physician-level case review of musculoskeletal utilization requests. Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service. Provides education regarding applicable clinical criteria and discusses clinically appropriate alternative surgical and non-surgical treatments. Performs first level provider appeals of coverage decisions. Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate musculoskeletal diagnoses, treatments, and management. Participates in physician team meetings. Participates in groups that develop, revise and enhance clinical appropriateness guidelines. Requires MD or DO and Board certification by the American Board of Orthopedic Surgery or American Osteopathic Board of Orthopedic Surgery. Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in appropriate state(s). Experience performing standard orthopedic procedures independently. Minimum of 3 years of clinical practice experience past fellowship training preferred. Extensive orthopedic surgery experience preferred. Experience with utilization management, especially with CMS guidelines preferred.