Medical Director Medical Policy

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

Provides clinical program leadership and develops, implements, and approves policies within a recognized area of responsibility. This role involves developing and maintaining medical policy, establishing rationale for approving inquiries and appeals, and assisting with clinical research, writing documents, and documenting decisions. The Medical Director will provide utilization management for prior authorization procedures, review cases and make decisions based on medical policy, and offer clinical support to various areas of the organization. Responsibilities also include processing requests for clarification, interpretation, or questions about policy or benefits, reviewing potential impacts of clinical matters, and serving as a clinical resource and subject matter expert to both clinical and non-clinical staff. The role also entails performing clinical reviews, conducting peer-to-peer discussions, and participating in JUMP committee meetings.

Requirements

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Seven (7) years clinical practice experience.
Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
Proven leadership, problem solving, and the ability to manage multiple priorities.
Strong teaching and communication skills.
Results oriented and the ability to take ownership for 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.

Nice To Haves

Specialty Care Knowledge 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 clinical resource and subject matter expert to both clinical and non-clinical staff.
Perform clinical reviews and conduct peer to peers.
Participate in JUMP committee meetings.