Medical Director Medical Policy, CMS/MA

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

Provides clinical program leadership and develops, implements, and approves policies within the recognized area of responsibility. The Medical Director develops and maintains medical policy, establishes rationale for approving inquiries and appeals, and assists with clinical research, document writing, and documentation of decisions. The role provides utilization management for prior authorization procedures, reviews cases, and makes decisions based on medical policy. It also provides clinical support across the organization, processes requests for clarification or interpretation of policy and benefits, and reviews the potential impacts of clinical matters. The Medical Director serves as a clinical resource and subject matter expert for clinical and non-clinical staff, performs clinical reviews, conducts peer-to-peer reviews, and participates in JUMP committee meetings.

Requirements

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.).
Seven years of clinical practice experience.
Current unrestricted State of Michigan M.D. or D.O. license.
Board certified, or board eligible and working toward certification, in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
Proven leadership, problem-solving, and ability to manage multiple priorities.
Strong teaching and communication skills.
Results-oriented, with the ability to take ownership of initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
Demonstrated skill with Microsoft Office Suite and web-based programs.
Understanding of health plan functions related to utilization, care, and quality management.
Other related skills and/or abilities may be required to perform this job.

Nice To Haves

Medicare experience is preferred.
Medical policy experience is a plus.

Responsibilities

Develop and maintain medical policy.
Establish rationale for approving inquiries and appeals.
Assist with clinical research, writing documents, and documenting decisions.
Provide utilization management for prior authorization procedures.
Review cases and make decisions based on medical policy.
Provide clinical support to various areas of the organization.
Process requests for clarification, interpretation, or questions about policy or benefits.
Review potential impacts of clinical matters.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Perform clinical reviews and conduct peer-to-peer reviews.
Participate in JUMP committee meetings.