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Anthem, Inc. Behavioral Health Medical Director - Appeals in San Jose, California

Description

SHIFT: Day Job

SCHEDULE: Full-time

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.

Behavioral Health Medical Director - Appeals (PS56512)

Location: This position is remote. It is preferred that candidates reside in Nevada, California, Georgia, Indiana, Louisiana, or Texas.

The Medical Director (Appeals) is responsible for the administration of physical and/or behavioral health medical services, to ensure the appropriate and most cost-effective medical care is received. Primary responsibility includes Behavioral Health Appeals for standard and expedited appeals. May be asked to participate in Fair Hearings. May be asked to participate in other Quality activities.

May also be responsible for the following:

  • Developing and implementing programs to improve quality, cost, and outcomes.

  • Providing clinical consultation and serve as clinical/strategic advisor to enhance clinical operations.

  • Identifying cost of care opportunities.

  • Serving as a resource to staff including Medical Director Associates.

  • May be responsible for an entire clinical program.

    Primary duties may include, but are not limited to:

  • Supports clinicians 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.

  • Conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.

  • Serves as a resource and consultant to other areas of the company.

  • May be required to represent the company to external entities and/or serve on internal and/or external committees.

  • May chair company committees.

  • Interprets medical policies and clinical guidelines.

  • May develop and propose new medical policies based on changes in healthcare.

  • Leads, develops, directs and implements clinical and non-clinical activities that impact health care quality cost and outcomes.

  • Identifies and develops opportunities for innovation to increase effectiveness and quality.

Qualifications

Minimum Requirements:

  • M.D. or D.O.

  • Current and active board certification in Psychiatry.

  • An active, unrestricted license to practice medicine.

  • 5 years of clinical experience or any combination of education and experience, which would provide an equivalent background.

  • Must be willing to obtain additional state medical licenses as required.

  • 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.

    Preferred Qualifications:

  • Child & Adolescent Certification preferred.

  • Addiction Medicine Certification.

  • Managed Care industry experience strongly preferred.

  • Utilization Management.

  • Medicaid or Medicare experience.

  • Multiple state medical licenses a plus.

    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.

    REQNUMBER: PS56512-California

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