Medical Director Utilization Management

Blue Cross Blue Shield of Michigan•Detroit, MI

About The Position

The Medical Director Utilization Management provides clinical expertise across the enterprise and is responsible for interpreting, recommending, and reviewing corporate and medical policies within areas of responsibility. The role advises on and collaborates in the development of clinical programs, and supports utilization management, quality management, and care management programs. The position helps design, develop, implement, and assess disease state management and health enhancement programs that support appropriate use of clinical resources and consistent, high-quality medical care. It provides clinical leadership for health promotion and education programs and the claims editing department, and helps establish corporate and regional programs to improve care quality, reduce medical costs, and achieve positive health outcomes. Serving as a clinical resource and subject matter expert for clinical and non-clinical staff, the Medical Director performs clinical reviews, peer-to-peer discussions, high-dollar claims reviews, and complex case reviews. The role also engages with physicians in the BCBSM network on medical policies, utilization management, claims editing, resource use, and quality, and participates in inter-rater reliability activities, committees, and workgroups to support departmental and corporate objectives.

Requirements

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O.).
Seven years of clinical practice experience.
Current unrestricted 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.
Ability to communicate effectively with external physicians and organizations.
Proven leadership and problem-solving skills, with the ability to manage multiple priorities.
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, as well as HEDIS/STARs and NCQA.
Familiarity with CMS regulations and standards.
Basic knowledge of evidence-based clinical decision support guidelines (InterQual).
Basic knowledge of CPT coding and guidelines.
Other related skills and/or abilities may be required to perform the job.

Nice To Haves

Two years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management.
Certification in Utilization Review and Health Care Quality & Management.

Responsibilities

Provide clinical expertise across the enterprise and interpret, recommend, and review corporate and medical policies within areas of responsibility.
Advise and collaborate in the development of clinical programs.
Provide clinical support for utilization management, quality management, and care management programs, and identify opportunities for improvement and efficiency.
Assist in designing, developing, implementing, and assessing disease state management and health enhancement programs that support appropriate use of clinical resources and consistent, high-quality medical care.
Provide clinical leadership for health promotion and education programs and the claims editing department.
Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs, and achieve positive health outcomes.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Perform clinical reviews and conduct peer-to-peer discussions.
Discuss medical policies, utilization management, claims editing, resource use, and quality with physicians in the BCBSM network.
Perform high-dollar claims and complex case reviews.
Participate in inter-rater reliability activities.
Participate in committees and workgroups to achieve department and corporate objectives.