Medical Director

Blue Cross and Blue Shield of Kansas•Topeka, KS

18h•Hybrid

About The Position

The Medical Director will serve as a clinical subject matter expert responsible for supporting the plan utilization management, medical review and population health management programs across all lines of BCBS Kansas lines of business. As a clinical subject matter expert, the Medical Director, may also as needed provide support to plan programs including but not limited to medical policy development, quality management, and provider network management. This position requires a strong clinical background, leadership skills, and the ability to promote collaboration across functional areas to achieve organizational goals and objectives. “This position is eligible to work remotely, hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.”

Requirements

Medical degree (MD or DO) from an accredited institution required.
Completion of residency training program in ABMS/AOA recognized clinical specialty required.
ABMS/AOA board certification in a relevant medical specialty required, adult primary care specialty preferred.
Current, active, and unrestricted medical license in a state to practice medicine in the state of Kansas required.
5+ years of clinical experience required.
Experience with managed care/health insurance preferred.
Experience with Medicare Advantage (MA) and/or Affordable Care Act (ACA) populations, including demonstrated involvement in Utilization Management (UM) reviews preferred.
Commitment to evidence-based medicine, quality improvement, and healthcare innovation.
Effective oral and written communicator.

Nice To Haves

Adult primary care specialty preferred.
Experience with managed care/health insurance preferred.
Experience with Medicare Advantage (MA) and/or Affordable Care Act (ACA) populations, including demonstrated involvement in Utilization Management (UM) reviews preferred.

Responsibilities

Support utilization management and medical review activities including prior authorization, concurrent review, appeals processes, and claim review to ensure the appropriate use of healthcare services and resources.
Provide clinical subject matter expertise to support medical necessity determinations and utilization review criteria.
Support the development and maintenance of medical policies, clinical guidelines, and coverage determinations based on evidence-based medicine.
Ensure alignment with organizational goals, industry standards, and best practices.
Foster collaboration and communication among cross-functional teams, including medical directors, pharmacy, behavioral health, care management, and operations professionals to develop integrated care management strategies and improve care coordination.
Provide clinical subject matter expertise across all BCBSKS lines of business.
Provide clinical subject matter expertise as needed to support clinical programs and initiatives aimed at improving health outcomes, reducing costs, patient safety and enhancing member satisfaction.
Analyze clinical data, identify opportunities for quality improvement, develop strategies to address gaps in care, reduce variation, and promote best practices.
Ensure compliance with state and federal regulations, accreditation standards, and health plan requirements related to utilization management, medical review, and medical policy.
Stay abreast of changes in healthcare policy and reimbursement and implement necessary measures to maintain compliance.