Clin Ops Assoc Medical Dir (US) - Cardiology
Elevance Health

Job Info

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- 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, state mandated policies, and CMS Coverage Determinations, as applicable.

- Perform physician-level case review of utilization requests involving cardiac and vascular procedures (coronary angiography, percutaneous coronary interventions, implanted cardiac devices and peripheral revascularization procedures.

- 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 treatments, procedures, 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 Carelon Medical Benefits Management policies pertaining to utilization review.

-Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to cardiology services and procedures. • Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate cardiac 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 Carelon Medical Benefits Management protocols, policies, and procedures.

Qualifications

- Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state

- Board Certification in Cardiovascular Disease, Interventional Cardiology or Vascular Surgery by the American Board of Internal Medicine

-3-5 years of clinical practice experience past fellowship training is desirable

-Demonstrated knowledge of current practice standards in cardiovascular medicine

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