Responsible for the administration of medical management services for company health plans and ensures clinical integrity of broad and significant clinical programs, including the overall medical policies of the Medicare business unit.

Primary duties may include, but are not limited to:

Evaluates requests for service coverage for medical necessityInterprets existing policies 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 health care quality cost and outcomes.Supports the Medical Management staff ensuring timely and consistent responses to members and providers.Identifies and develops opportunities for innovation to increase effectiveness and quality.Serves as a resource and consultant to other areas of the company.May chair or serve on company committees.May be required to represent Anthem to external entities and/or serve on external committees.QualificationsRequires MD; or DOAt least 5 years of experience with extensive managed care or Medicare knowledge; or any combination of education and experience, which would provide an equivalent background.ABMS recognized board certification required.Previous UM/appeals experience preferred.Internal Medicine, Emergency Medicine, and/or Family Practice, Neurology or Radiology Board Certification preferred.

Associated topics:
bilingual, care, care physician, family practice, family practice physician, general practice, outpatient, physician md do, primary, primary care

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