Sr Medical Director

Blue Cross and Blue Shield of Nebraska • Omaha, ND

2d • Hybrid

About The Position

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there’s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you’ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community. The Senior Medical Director, Utilization Management is the physician leader accountable for strategic and operational leadership of utilization management (UM) programs across commercial, ACA, and/or Medicare Advantage lines of business. This role provides enterprise-level clinical leadership to ensure UM programs improve quality, appropriateness of care, provider collaboration, and total cost of care, while meeting regulatory, accreditation, and compliance standards. This position serves as the senior clinical authority for UM policy, decision-making, and performance, and leads other Medical Directors and clinical staff engaged in utilization review, prior authorization, and medical necessity determinations. Candidates applying to this position may be hybrid or remote and can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas. The candidate selected for this role will be required to visit the Omaha based job site for occasional strategic meetings throughout the year.

Requirements

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board Certified by an American Board of Medical Specialties (ABMS) board.
• Preferred current, unrestricted medical license in Nebraska. If not currently actively licensed in Nebraska, verification of attainment within 6 months of start.
• 10+ years of combined clinical practice and health care industry experience.
• Demonstrated experience in utilization management, medical necessity review, and physician peer review
• Demonstrated effective communication skills, a commitment to continuous improvement in healthcare delivery, and the ability to adapt to a dynamic and rapidly evolving healthcare environment
• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).
• Board Certified by an American Board of Medical Specialties (ABMS) board.
• Active, current, and unrestricted Nebraska clinical license within 6 months of start date that would allow the incumbent to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination.
• 10+ years of combined clinical practice and health care industry experience.
• Demonstrated experience in utilization management, medical necessity review, and physician peer review.
• Demonstrated effective communication skills, a commitment to continuous improvement in healthcare delivery, and the ability to adapt to a dynamic and rapidly evolving healthcare environment.
• An equivalent combination of education and experience may be substituted for this requirement.
• The ability to meet or exceed the attendance and timeliness requirements of their departments.
• The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

Nice To Haves

• Prior experience in a senior or enterprise-level UM leadership role.
• Three + years Managed care experience across Commercial and/or Medicare Advantage populations.
• Experience leading or overseeing other Medical Directors.
• Strong background in quality improvement, population health, and cost containment initiatives.
• Prior experience in a senior or enterprise-level UM leadership role.
• Three + years Managed care experience across Commercial and/or Medicare Advantage populations.
• Experience leading or overseeing other Medical Directors.
• Strong background in quality improvement, population health, and cost containment initiatives.

Responsibilities

• Provide clinical leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals.
• Set UM strategy aligned with organizational goals for affordability, quality, member experience, and regulatory compliance.
• Serve as senior clinical advisor to executive leadership on utilization trends, risk areas, and intervention opportunities.
• Oversee the medical policy team, development and refinement of utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual)
• Lead the Medical Policy and Utilization Management Governance Committees
• Oversee complex and high-risk utilization review cases, including medical necessity determinations and claim reviews.
• Conduct clinical reviews and/or oversee peer-to-peer reviews with ordering and attending providers.
• Ensure consistent, evidence-based application of clinical guidelines and medical policy across all UM functions.
• Provide clinical expertise to teams conducting coding, payment integrity, and reimbursement activities.
• Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care.
• Act as senior clinical UM liaison to network providers, facilities, and delegated UM partners.
• Build and maintain strong physician relationships to support appropriate utilization, practice transformation, and quality improvement.
• Represent Medical Management in cross-functional leadership forums (Quality, Network, Pharmacy, Population Health).
• Lead development and implementation of UM interventions that reduce unnecessary utilization while maintaining or improving quality outcomes, including strategies for integration of AI technologies to improve efficiency, accuracy of reviews, and user experience.
• Review utilization data, denial patterns, appeals outcomes, and inter-rater reliability results to identify improvement opportunities and develop solutions for implementation and continuous quality improvement
• Oversee performance and outcomes generated by contracted UM vendors
• Ensure UM programs meet CMS, URAC, and state regulatory requirements.
• Support workforce development, consistency of decision-making, and clinical calibration across UM teams.
• Conduct and support training of medical directors and UM staff

Benefits

• We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.
• On the cutting edge of the health care industry, helping Nebraskans in moments of joy, times of hardship and the steps in between.
• We are Blue Cross and Blue Shield of Nebraska (BCBSNE), and we exist to be there for people when they need us.
• Our goal is to add more good, healthy years to people’s lives by supporting our customers and the Nebraska community at large.
• We have more than 80 years of experience behind us. And a bright future ahead as we continuously innovate to drive health care forward while meeting the needs of our members and state.
• If you’re passionate about helping people along their health journeys, we invite you to explore our career offerings.
• Here, you will find opportunities to grow personally and professionally while making a difference for our customers and greater Nebraska community.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Ph.D. or professional degree