Anthem, Inc. Associate Medical Director - Pain in Upland, California
SHIFT: Day Job
AIM is currently seeking a Board-Certified Pain Management Physician to participate in pre-authorization and quality improvement solutions for interventional pain management procedures involving the spine and high-tech diagnostic musculoskeletal imaging. Medical Directors in Clinical Operations determine the medical necessity of requests using clinical appropriateness guidelines and health plan medical policy.
Location: Work at home
Successful candidates will:
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, and CMS Coverage Determinations, as applicable.
Perform physician-level case review of interventional pain management utilization requests involving the spine such as epidural injections (interlaminar/caudal and transforaminal), epidural adhesiolysis, facet joint injection, radioablation, regional sympathetic nerve block, sacroiliac joint injections, spinal cord stimulators, and thermal intradiscal procedures following initial clinical review by a therapist reviewer or a nurse reviewer.
Perform physician-level case review of high-tech diagnostic musculoskeletal imaging requests following initial clinical review by a therapist reviewer or a nurse reviewer.
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 interventional pain management treatments, 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 AIM policies pertaining to utilization review.
Demonstrate and maintain knowledge of applicable ICD-10, HCPCS, and CPT coding guidelines as it relates to interventional pain management services and procedures.
Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal 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 AIM Specialty Health protocols, policies, and procedures.
- Requires an MD and Board certification in a medical specialty required
Board Certification in Pain Management by the American Board of Anesthesiology, The American Board of Psychiatry and The American Board of Neurology, or the American Board of Physical Medicine and Rehabilitation
3-5 years of clinical practice experience post-fellowship training is preferred.
Demonstrated knowledge of current practice standards in interventional pain management.
Strong oral communication and interpersonal skills.
Computer literacy with the ability to learn new applications.
Strong analytical skills.
Ability to multi-task.
Ability to work both independently and in a team environment.
Ability to work in a dynamic, fast-paced environment
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Anthem approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require an accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.