Director, Medical Operations - Atlanta PS28641

Job Description

Your Talent. Our Vision. At Anthem Blue Cross and Blue Shield , a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care . This is an exceptional opportunity to do innovative work that means more to you and those we serve.

Director Medical Operations

Location: Anthem office on 3350 Peachtree Road, Atlanta, GA

Responsible for the day to day medical management operations along with local quality and improvement initiatives for the Georgia State Health Plan. Primary duties may include, but are not limited to:

Medical Operations:

• Interprets 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.
• Conduct peer clinical and/or appeal case reviews and peer to peer clinical reviews with attending physicians or other ordering providers to discuss review determinations
• 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 as needed.

Provider Collaboration and External-Facing:

• Serves on company committees and represents Anthem to external entities and/or serve on external committees.
• Provides expertise, captures and shares best practices across regions to provider partners as well as Anthem medical directors.
• Serves as a resource and consultant to providers in a region.
• Engages with providers in joint operating committees and builds relationships with clinical leadership of provider collaboration groups.

Leadership and Strategy:

• Drives strategies around cost of care and analytic tools and reporting.
• Provides guidance for clinical operational aspects of the program and supports the medical management staff ensuring timely and consistent responses to members and providers.
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requires M.D. or D.O.; board certification approved by the American Board of Medical Specialties where applicable to duties being performed; must possess an active unrestricted medical license to practice medicine or a health profession. 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, and ; 10 years of clinical experience ; or any combination of education and experience, which would provide an equivalent background. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

• Managed Care knowledge and experience.
• Knowledge of healthcare delivery systems.
• Prior external-facing experience or interest in external-facing role.
• Excellent communication and strong negotiation skills to drive collaborative resolution.
• Appropriate poise and polish to interact with hospital administrators, providers, and medical practice leadership at a high level.
• Willing and able to travel within the state to meet with providers.

Familiarity with Georgia provider market.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.