Medical Director - Hybrid

Blue Cross Blue Shield of Arizona•Phoenix, AZ

101d•Hybrid

About The Position

Blue Cross Blue Shield of Arizona (BCBSAZ) is seeking a Medical Director to lead and provide professional oversight for medical management activities including utilization management, case management, disease management, and quality management. This role supports collaborative relationships with physicians and hospitals to achieve business goals and ensure medical policies and practices align with community standards. BCBSAZ operates under a hybrid workforce strategy called Workability, offering flexibility in how and where employees work. This specific position is classified as hybrid, requiring residency and work within the State of Arizona, with an onsite expectation of at least one day per week.

Requirements

3 years of experience in a clinical setting
1 year of experience in a physician leadership role, including quality review, utilization review, and other managed care functions
Medical Degree
Active, current, and unrestricted license to practice medicine in the State of Arizona
Board Certification

Nice To Haves

3 years of experience in a primary care field

Responsibilities

Provide direction, support, medical expertise, and oversight to areas within the Health Services Division, including utilization management, quality management, case management, medical claims review, and pharmacy management.
Manage specific activities such as outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration, and retrospective review.
Offer consultative services across the corporation to divisions including Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims.
Communicate with customers regarding difficult and costly cases, providing recommendations and demonstrating the impact of BCBSAZ interventions.
Enhance department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense.
Review and implement medical policies and other medical decision-making policies or procedures.
Represent BCBSAZ at professional organizations and act as a liaison with healthcare professionals, supporting collaborative relationships with physicians and hospitals.
Provide professional oversight for clinical peer committees, including the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee.
Participate in appeals and grievance processes to ensure timely and accurate responses to members and providers.
Conduct Appeal Peer Review cases as appropriate, adhering to required qualifications.
Provide written information to members and providers through letters and articles in newsletters and other publications.
Foster productive relationships with employers, members, and providers to ensure members receive appropriate healthcare in the most appropriate setting with the best value.
Lead staff and other professionals through clinical excellence, professional behavior, and innovative thinking.
Monitor quality performance measures, develop and maintain effective workflows, and maximize system efficiencies.
Identify opportunities to achieve administrative efficiencies while maintaining service levels.
Maintain effective working relationships to ensure teamwork in achieving corporate goals.
Contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.
Coordinate activities between multiple divisions to achieve desired results.
Perform all other duties as assigned.