Medical Director Utilization Management

Blue Cross Blue Shield of Michigan•Detroit, MI

22h

About The Position

Provide clinical expertise across the enterprise for various functions. Interpret, recommend, and review corporate and medical policies within recognized areas of responsibility, and advise and collaborate in developing clinical programs. Provide clinical support and participate in utilization management, quality management, and care management programs, identifying opportunities for improvement and efficiency. Assist with the design, development, implementation, and assessment of 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. Help establish 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. Conduct clinical reviews, peer-to-peer discussions, high-dollar claims reviews, and complex case reviews. Discuss medical policies, utilization management, claims editing, resource use, and quality with physicians in the BCBSM network. Participate in inter-rater reliability activities, committees, and workgroups to achieve department 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, and ability to manage multiple priorities.
Results-oriented; able to take ownership of 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, 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 this 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.
Advise and collaborate in the development of clinical programs.
Provide clinical support and participate in utilization management, quality management, and care management programs; identify opportunities for improvement and efficiency.
Assist in designing, developing, implementing, and assessing disease state management and health enhancement programs.
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.