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 an area of responsibility. Develops and maintains medical policy and establishes rationale for approving inquiries and appeals. Assists with clinical research, writing documents, and documenting decisions. Provides utilization management for prior authorization procedures, reviews cases, and makes decisions based on medical policy. Provides clinical support across the organization, processes requests for clarification or interpretation of policies or benefits, and reviews potential impacts of clinical matters. Serves as a clinical resource and subject matter expert for clinical and non-clinical staff. Performs clinical reviews and conducts peer-to-peer discussions. 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 and problem-solving skills, with the ability to manage multiple priorities.
Strong teaching and communication skills.
Results-oriented, able to take ownership of initiatives, and able to 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 the job.

Nice To Haves

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

Responsibilities

Provide clinical program leadership and develop, implement, and approve policies within the area of responsibility.
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 discussions.
Participate in JUMP committee meetings.