Anthem, Inc. Associate Medical Director - AIM Specialty Health in Clearwater, Florida
SHIFT: Day Job
Your Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater 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.
We are currently seeking a versatile Board Certified Physician to participate in pre-authorization reviews of high-tech diagnostic imaging, cardiac testing and sleep management services. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cardiology and sleep management requests using clinical guidelines and health plan medical policy.
Successful candidates will:
Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging. Imaging modalities include CT, CTA, MRI, MRA, PET, and Nuclear Cardiology.
Determine medical necessity of requests using AIM Medical Necessity Guidelines and client-specific health plan medical policy.
Conduct peer-to-peer discussions with ordering physicians, physician assistants, and nurse practitioners to provide education regarding established guidelines and accepted standards of care as they pertain to the use of diagnostic imaging studies, cardiac testing and sleep management services.
Suggest alternatives services to ordering providers when appropriate.
Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application.
Demonstrate and maintain current knowledge of modalities and new applications of known technologies for diagnostic imaging, cardiac services and sleep management.
As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered modalities.
Participate in periodic physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of diagnostic imaging procedures, cardiac services and sleep management.
Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert.
Perform first level provider appeals as designated by the client for adverse determinations.
Obtain additional state licensure based upon business needs.
Adhere to all AIM Specialty Health Management protocols, policies, and procedures.
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification by American Board of Medical Specialties
Internal Medicine, Family Medicine and Emergency Medicine preferred
Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Strong analytical skills
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.