Medical Director (Medicare Policy)

BlueCross BlueShield of South Carolina•Tennessee, IL

23h•Remote

About The Position

Analyzes medical review utilization data, researches new medical procedures or technology, and acts as a lead resource to providers and internal staff on issues concerning medical policies. Heavily involved in policy generation to include the development of new policy and the revision of old policy. This role is centered on policy expertise rather than organizational clinical leadership. While highly impactful, the scope is focused on Medicare policy development, interpretation, and guidance. It does not include enterprise clinical leadership, direct reports, or executive-level strategic ownership.

Requirements

Doctorate in a job-related field
Active state medical license and current board certification in a recognized specialty.
5 years post graduate experience in direct patient care.
Excellent verbal and written communication skills.
Excellent customer service, organizational, and presentation skills.
Good judgment skills.
Proficiency in spelling, punctuation, and grammar.
Ability to persuade, negotiate, or influence others.
Ability to work as a team member as well as a leader.
Knowledge of medical and utilization review techniques.
Microsoft Office.
Must be a U.S. Citizen to obtain a security clearance.

Nice To Haves

Highly inquisitive, Self-Starter
Advanced problem solving skills
Medicare Part A experience
Strong client facing, relationship building skills
Ability to follow the Scientific Method

Responsibilities

Supports operations in the form of case review on both medical and regulatory matters.
Develops claim adjudication criteria for situations requiring medical judgment.
Provides input on issues and operational policies, processes, and procedures.
Educates staff and medical community on various aspects of medical policy and program administration.
May develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
Develops external relationships with the medical community and serves as liaison between these entities and the contractors.
Reviews physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
Conducts research into new or controversial medical procedures and technology.