*The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.
The position supports medical management and administrative operations activities. The incumbent will play a key role in ensuring the Division’s performance and compliance with regulations and contract agreements related to the various products and other managed government programs. He or she will lead, direct and supervise various components of Medical Management Operations and Quality Initiative Programs. The Medical Director will provide clinical leadership for various committees and will act as an internal medical consultant to various BCBST divisions, departments and committees to support the development, implementation and monitoring of medical management and quality initiative activities. The incumbent will be available to represent the Company with CMS and other external entities on matters related to medical management activities, and quality improvement programs as directed by the CMO.
Job Duties & Responsibilities
- Maintain working knowledge of all applicable managed programs.
- Supervise medical directors who perform physician review as directed by the CMO
- Work closely with company analytic teams to coordinate, analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement activities to effectively manage utilization and cost trends.
- Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
- Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.
- Lead and serve on various committees appropriate to accomplishing the medical utilization, cost and quality objectives of BCBST.
- Support the Medical Management and Quality Programs through systematic education and information sharing.
- Other duties as assigned.
- MD or DO with unrestricted license to practice medicine in Tennessee.
- Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists.
- Advanced degree in health informatics and/or extensive experience with clinical data analysis preferred.
However, this requirement can be waived for jobs where the totality of the incumbent’s duties and responsibilities are restricted to the performance of administrative duties only.
- Minimum of 5 years clinical experience and 5 years of healthcare administration, including UM experience.
- Strong presentation, communication and negotiation skills.
- Ability to work effectively within a team environment
- Ability to interpret and explain complex government policies
- Willingness to travel within the State of Tennessee and nationally.
- Willingness to be innovative and take risks.
- Knowledge of personal computers and software programs, especially Microsoft Office, Outlook and Excel needed.
- Working knowledge of Care Advance and Facets preferred.
- Knowledge of Medicare programs is desirable
Job Specific Requirements:UM experience with Medicare Advantage highly preferred
Advanced business degree preferred
Experience managing Medical Directors in a managed care environment preferred
Number of Openings Available:1
Company:BCBST BlueCross BlueShield of Tennessee, Inc.
BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or membership in a historically under-represented group.
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.
Tobacco-Free Hiring Statement
To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.
Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.