Medical Director, Utilization Management

BlueCross BlueShield of Vermont•Berlin, VT

7d•$240,000 - $300,000•Hybrid

About The Position

Blue Cross and Blue Shield of Vermont is looking for a Medical Director, Utilization Management to lead our UM team. Our company culture is built on an unwavering focus on the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. We offer a balanced and flexible workplace, an onsite gym, fitness and wellness programs, a competitive salary and full benefits package including medical and dental insurance, vision, 401K, paid time off and holidays, tuition reimbursement and student loan repayment, dependent caregiver benefits, and resources to support your ongoing personal and professional growth and development.

Requirements

Unrestricted Vermont medical license compliant with leadership and infrastructure requirements of Vermont State Law, URAC, and NCQA.
M.D. or D.O. degree.
Board certification in an American Board of Medical Specialties (ABMS) approved specialty.
Seven to ten (7-10) years of clinical practice experience combined with three (3) years of clinical management experience serving as a physician reviewer for UM, prior authorization, and appeals in a health plan or managed care environment.
Must be able to work a hybrid schedule working a minimum of one to two (1-2) days onsite; with Vermont residency preferred.

Nice To Haves

Prior medical administrative background is highly desirable.
Advanced management degree or equivalent preferred.
Excellent knowledge of local health care delivery systems and existing relationships with local network providers and medical facilities is highly desirable.

Responsibilities

Serve as the physician leader for medical management, with primary accountability for utilization management (UM) decision making, including physician-level medical necessity determinations, prior authorization reviews, appeals, and provider-to provider discussions.
Oversee the work of the Director, UM and works closely with the UM team and other Medical Directors to ensure reviews are completed within required state and NCQA timeframes.
Serve as the final clinical authority for medical necessity determinations in accordance with medical policy and regulatory requirements.
Contribute to the continuous improvement of UM operations to enhance efficiency, consistency, and effectiveness, and partners with the Quality, Case Management, Provider Relations, and Payment Integrity teams to support coordinated care, improved member outcomes, and using lower cost, effective alternatives for responsible healthcare cost management.
Play a key role in developing, training, and supporting UM staff, and actively uses UM technology platforms and clinical criteria systems to support high-quality, timely decision making.