Plan Performance Medical Director at ELEVANCE HEALTH INC

Lubbock, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

06 Mar, 26

Salary

450432.0

Posted On

06 Dec, 25

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Experience, Medical Policies, Cost-Effective Care, Communication Skills, Problem-Solving Skills, Analytical Skills, Leadership, Innovation, Collaboration, Clinical Guidelines, Peer-to-Peer Reviews, Operational Guidance, Committee Representation, Data Analysis, Presentation Skills, Excel Proficiency

Industry

Hospitals and Health Care

Description

Anticipated End Date: 2025-12-13 Position Title: Plan Performance Medical Director Job Description: Plan Performance Medical Director Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations can be considered. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Plan Performance Medical Director serves as a lead clinician and oversees the administration of medical services for the individual ACA health plans across 17 states. This role involves managing the overall medical policies and clinical guidelines to ensure appropriate and cost-effective care. The Director also leads initiatives to direct the plan regarding cost of care and other strategic directives. Additionally, this position involves collaborating with market plan presidents during meetings with state regulators. How you will make an impact: 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. Minimum Qualifications: 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. 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. 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. Travels to worksite and other locations as necessary. If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed. Preferred Skills, Capabilities and Experiences: Experience with clinical finance data, as well as medical cost and trend analysis. Strong communication skills, including both presentation and writing abilities. Proficiency in Excel and PowerPoint. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $275,264 to $450,432. Locations: Woodland Hills, CA; Denver, CO; Mendota Heights, MN; New York City, NY. In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Director Equivalent Workshift: Job Family: MED > Licensed Physician/Doctor/Dentist Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. 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. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading. Join our Talent Community and stay connected with company news, information, and future job opportunities. Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner. Our nearly 100,000 associates serve approximately 100M+ people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health. Please visit the Contract Worker Community Page. Elevance Health is an Equal Opportunity Employer/Disability/Veterans.

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Responsibilities

The Plan Performance Medical Director oversees the administration of medical services for ACA health plans across 17 states, managing medical policies and clinical guidelines. This role also involves collaborating with market plan presidents and leading initiatives to direct cost of care.