Physician Advisor

BlueCross BlueShield of South Carolina•Columbia, SC

6d•Hybrid

About The Position

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team! Position Purpose: The Physician Advisor optimizes efficient management of resources, ensuring patients are in the appropriate level of care, supporting documentation, coding improvements and compliance, and monitoring the appropriate use of diagnostic and therapeutic modalities. Provides assessment and determination of medical necessity in case evaluation and utilization management. Collaborates with a multidisciplinary team to implement methods and develop care management protocols that optimize the use BCBSSC services for all patients while ensuring quality care is provided. Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment, with the opportunity to have a hybrid work schedule after training. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located at 4101 Percival Road, Columbia, SC 29229.

Requirements

Medical Doctor (MD) or Osteopathic Doctor (DO) with current license to practice.
8 years-broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training.
Demonstrated ability to direct multiple strategic projects.
Excellent verbal and written communication skills.
Excellent judgment, organizational, customer service, presentation skills.
Excellent analytical or critical thinking skills.
Knowledge of strategic concepts.
Ability to persuade, negotiate, or influence others.
Microsoft Office.
Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.

Nice To Haves

2 years-medical data analysis/analytical capability to interpret statistical information.
Experience with medical oversight of quality improvement activities.
Experience with quality committees or NCQA.
Experience with population based disease management or public health initiatives.
Experience in medical management or managed care.
Demonstrated understanding of Medicare programs.

Responsibilities

Communicates with hospital physicians, care coordination and utilization management (UM) staff to champion best practices for evidence-based care and its documentation.
Provides valuable guidance on matters regarding physician practice patterns, over- and under-utilization of resources, medical necessity, documentation best practices, level of care progression, denial management, and compliance with governmental regulations.
Performs UM review functions including pre-admission reviews, continues stay reviews, procedure precertification's, post-service reviews, emergency room visit reviews, and individual case management needs.
Responds to requests for assistance on clinical reviews for medical necessity or any other reason, by any member of the Case Management department in a timely fashion.
Keeps abreast of current CMS and MCG evidence-based guidelines to enable UM decisions.
Maintains compliance with legal, regulatory and accreditation requirements and payor partner policies.
Uses, protects and discloses patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Serves as medical resource for quality improvement.
Functions as liaison to medical community.
Acts as resource for providers/internal staff on medical policies.
Educates providers on issues concerning medical policies, utilization specifications, and coding/medical necessity issues.
Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations.
Participates in medical review policy/quality programs and inter-reviewer reliability studies