Elevance Health
Medical Director - Florida Medicare Plans
Elevance Health is looking for a Medical Director to support Florida Medicare plans including Simply Healthcare Plans, Healthsun Plans, Freedom Health, and Optimum Healthcare Plans. The role focuses on utilization review case management, program development, and clinical consulting.
Key Responsibilities
Supports clinicians to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Performs utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines).
Collaborates with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
Provides peer‑to‑peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.
Ensures timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards.
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 external committees.
Might 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.
Expects weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.
Minimum Requirements
MD or DO with Board certification approved by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
Active unrestricted medical license to practice medicine in Florida.
Located in a U.S. state or territory when conducting utilization review or appeals, not on a U.S. military base, vessel, or embassy.
Minimum of 10 years of clinical experience, or an equivalent combination of education and experience.
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by state contracts or regulations if the role is filing a state agency position.
Preferred Qualifications
Bilingual – Spanish speaking preferred.
Utilization Management case review experience strongly preferred.
Previous experience working for a health plan or managed care organization preferred.
Previous Medicare experience preferred.
Internal/Family Medicine or other adult medicine training preferred.
Equal Employment Opportunity 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.
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Key Responsibilities
Supports clinicians to ensure timely and consistent responses to members and providers.
Provides guidance for clinical operational aspects of a program.
Performs utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines).
Collaborates with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.
Provides peer‑to‑peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.
Ensures timely and accurate completion of reviews in compliance with state and federal regulations, NCQA, and company standards.
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 external committees.
Might 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.
Expects weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.
Minimum Requirements
MD or DO with Board certification approved by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA).
Active unrestricted medical license to practice medicine in Florida.
Located in a U.S. state or territory when conducting utilization review or appeals, not on a U.S. military base, vessel, or embassy.
Minimum of 10 years of clinical experience, or an equivalent combination of education and experience.
For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required. Additional experience may be required by state contracts or regulations if the role is filing a state agency position.
Preferred Qualifications
Bilingual – Spanish speaking preferred.
Utilization Management case review experience strongly preferred.
Previous experience working for a health plan or managed care organization preferred.
Previous Medicare experience preferred.
Internal/Family Medicine or other adult medicine training preferred.
Equal Employment Opportunity 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.
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