Medicare Operations Manager Jobs in Florida (NOW HIRING)

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Medical Director- Florida Medicare

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. 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. Prefer candidates that live near a location in Florida. Alternate locations may be considered.

The Medical Director is responsible for utilization management, medical necessity clinical reviews of both inpatient and outpatient authorizations, appeals medical necessity reviews, and peer to peer clinical discussions. Additionally, responsibilities will include active participation in assigned committees such as peer review committee, credentialing committee, quality committees, etc. This medical director may be asked to participate in cost of care initiatives and lead projects assigned. This role requires weekend on call expectations given UM requirements and turnaround time compliance standards as set by Medicare.

How you will make an impact:

• Supports clinicians to ensure timely and consistent responses to members and providers.

• Provides guidance for clinical operational aspects of a program.

• Perform utilization management reviews to determine medical necessity and appropriateness of care, using nationally recognized criteria (e.g., MCG, InterQual, CMS guidelines).

• Collaborate with UM nurses and case managers to review inpatient admissions, outpatient procedures, and continued stays.

• Provide peer-to-peer discussions with treating physicians to discuss medical necessity decisions and care alternatives.

• Ensure 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/or external committees.

• May 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.

• Expectation for this role also includes weekend and holiday coverage during assigned weekend rotations to support continuity of UM operations and ensure timely case processing.

Minimum Requirements:

• 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).

• Must possess an active unrestricted medical license to practice medicine or a health profession in Florida.

• 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 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 Medical Director is filing a role required by a State agency.

Preferred Qualifications:

• Previous Medicare experience preferred.

• Internal/Family Medicine or other adult medicine training preferred.

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Workshift:

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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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. 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.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words - the job is posted until 3/13, not through 3/13.