Anthem, Inc. Associate Medical Director - Orthopedic Surgery in Modesto, California
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.
Responsible for performing pre-authorizations and providing quality improvement solutions for musculoskeletal procedures involving 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 nonsurgical 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 M.D. or D.O. 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 joint procedures independently.
Preferred Criteria in Addition to Requirements:
3-5 years of clinical practice experience past fellowship training preferred.
Extensive spine surgery experience preferred.
Experience with utilization management, especially with CMS guidelines preferred.
Intermediate computer skills 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. 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.