Clinical Compliance Medical Director

Clinical Compliance Medical Director

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.

The Clinical Compliance Medical Director is responsible for providing clinical guidance related to the company's coding guidelines, provider coding audits, and participates in developing an investigation team that focuses on potential fraud, waste, and abuse in the provider population.

How will you make an impact:

• Reviews provider medical record documentation to determine if there is potential fraud, waste, or abuse that warrants further investigations.
• Conducts provider interviews related to these investigations.
• Investigative material which includes provider medical record documentation.
• Provides clinical guidance regarding coding guidelines and develops provider educational material.
• Develops a more clinically focused provider audit process to obtain more meaningful results.
• Develops clinical review for investigations team including developing guidelines on how to implement the clinical analysis portion of the investigations and developing clinically relevant questions for provider interviews.
• Develops provider educational materials that are clinically focused and provides peer-to-peer compliance training and education to other providers internally and externally.
• Provides input to provider reporting from the provider perspective.

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).
• Requires active unrestricted medical license to practice medicine or a health profession.
• Clinical training and practice as a primary care physician required.
• Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Deep understanding of CMS-HCC and/or HHS-HCC risk adjustment methodologies strongly preferred.
• Certified Risk Adjustment Coder (CRC) or similar credential strongly preferred.
• Experience with clinical documentation improvement and coding practices (ICD-10, HCC, MEAT criteria) strongly preferred.
• Certified Clinical Documentation Improvement Practitioner (CDIP) or similar credential strongly preferred.
• Experience in RADV audit preparation or payer-provider collaboration strongly preferred.
• Experience in OIG and CMS investigations strongly preferred.
• Experience writing expert reports and/or expert testimony related to false claims strongly preferred.

Job Level: Director Equivalent

Workshift:

Job Family: MED > Licensed Physician/Doctor/Dentist

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.

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 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.