Anthem, Inc. Associate Medical Director or Medical Director (Oncology) AIM Specialty Health in Mason, Ohio
SHIFT: Day Job
Clinical Operations Associate Medical Director or Medical Director Location: This position has been approved to work remote, anywhere in the US with preference given to candidates located in California.
Be part of an extraordinary team We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
Build the Possibilities. Make an extraordinary impact. AIM Specialty Health is a benefit-management leader in Illinois and a proud member of Anthem's family of companies. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.We are currently seeking several versatile Board Certified Medical Oncologists to participate in pre-authorization reviews related to oncology care. Medical Directors in Clinical Operations determine the medical necessity of outpatient radiology, cancer chemotherapy and genetic testing requests using clinical guidelines and health plan medical policy.
How you will make impact:
Determine medical necessity of requests using applicable clinical criteria, which may include AIM Appropriateness Guidelines, client-specific health plan medical policy, well-established evidenced-based guidelines, and CMS Coverage Determinations, as applicable.
Perform physician-level case review of interventional pain management utilization requests involving the spine such as epidural injections (interlaminar/caudal and transforaminal), epidural adhesiolysis, facet joint injection, radioablation, regional sympathetic nerve block, sacroiliac joint injections, spinal cord stimulators, and thermal intradiscal procedures following initial clinical review by a therapist reviewer or a nurse reviewer.
Perform physician-level case review of high-tech diagnostic musculoskeletal imaging requests following initial clinical review by a therapist reviewer or a nurse reviewer.
Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to interventional pain management treatments, imaging, and appropriate sites of service.
Discuss clinically appropriate alternative treatments, imaging studies, and sites of care with ordering providers when consistent with applicable clinical criteria.
Provide education regarding applicable clinical criteria.
Perform first-level provider appeals of coverage decisions.
Demonstrate and maintain knowledge of applicable clinical criteria and relevant AIM policies pertaining to utilization review.
Demonstrate and maintain knowledge of applicable ICD-10, HCPCS, and CPT coding guidelines as it relates to interventional pain management services and procedures.
Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.
Actively participate in physician team meetings.
Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
Obtain additional state licensure based upon state regulations and health plan needs.
Adhere to all AIM Specialty Health protocols, policies, and procedures.
Requires an MD and minimum of 1 year of experience with clinical case reviews for medical necessity.
The minimum of 1 year of experience with clinical case reviews would be waived for the following specific specialties only; Cardiology, Oncology, and Interventional Pain specialties.
Board certification in a medical specialty required. This job is paid on an hourly basis.
Board Certification American Board of Medical Specialties in Medical Oncology or Radiation Oncology
3-5 years of clinical practice experience post-fellowship training is preferred.
Demonstrated knowledge of current practice standards in interventional pain management.
Strong oral communication and interpersonal skills.
Computer literacy with the ability to learn new applications.
Strong analytical skills.
Ability to multi-task.
Ability to work both independently and in a team environment.
Ability to work in a dynamic, fast-paced environment
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem 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 firstname.lastname@example.org for assistance.