Anthem, Inc. Plan Performance Medical Dir in Columbia, South Carolina
SHIFT: 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.
Plan Performance Medical Director - Requires residency in the tri-state area (NY, NJ, southern CT)
Primary duties may include, but are not limited to:
Supports the Medical Management staff to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients’ office visits with providers and external physicians.
May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
Interprets existing policies or clinical guidelines 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 efficient and effective care.
Identifies and develops opportunities for innovation to increase effectiveness and quality.
Provides expertise, captures and shares best practices across regions to other medical directors.
May chair or serve on company committees, may be required to represent the company to external entities and/or serve on external committees.
Ability to effectively interface with external parties (e.g., hospital association, medical society, accounts, hospitals/provider groups, regulators, etc.)
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).
Requires active unrestricted medical license to practice medicine or a health profession in the State of New York or able to apply for one. 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.
Requires residency in the tri-state area (NY, NJ, southern CT). Required travel to the office at least a couple of times a week upon opening of offices.
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.
Population health experience; adept at building links to local community providers.
Managed care background and ability to converse about UM, claims, contracting, regulatory, and other managed care issues with hospitals and provider groups.
Ability to support internal teams (e.g., Sales, Government Relations, Legal, Contracting, etc.) and to effectively interface with external parties (e.g., hospital association, medical society, accounts, hospitals/provider groups, regulators, etc.)
The health and safety of our associates, members and communities is a top priority for Anthem. This priority has become increasingly important as we continue to face the challenges of the COVID-19 pandemic. Anthem believes vaccination is the best way to reduce the spread of COVID-19 and protect our members, our communities, our families and ourselves. To minimize the risk of transmission of the COVID-19 virus and maintain a safe and healthy workplace, vaccination is required for this role. (At Anthem, fully vaccinated means it has been at least two weeks since you have received the second dose of a two-dose vaccine such as Moderna or Pfizer, or the single dose of a single dose vaccine, such as Johnson & Johnson ).
If you do not meet the requirements for this position, we encourage you to review other positions that currently allow virtual work. If you have a medical or sincerely held religious reason for not being vaccinated, consistent with applicable law, Anthem will consider requests for reasonable accommodation on this basis. Should you have any questions regarding the requirement after applying, email TalentAcquisition_VaccinationSupport@anthem.com
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.
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. 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.