VP, Medical Affairs

BlueCross BlueShield of South Carolina•Columbia, SC

22d•Onsite

About The Position

As the Vice President of Medical Affairs, you will provide direct physician support to all areas of commercial lines of business, including but not limited to Preferred Blue and FEP Health Care Services and National Alliance areas. In this role, you will function in a consultant capacity to other areas of the company including Corporate Audit, the various claims areas Marketing, Benefit Files, and Underwriting. Additional responsibilities include case evaluation, case escalations, complaint review, training, and policy development, as well as providing medical support to the quality management program of all commercial products. The Vice President of Medical Affairs is also the Medical Director to the State HealthPlan performing all of the functions that are listed for Preferred Blue and FEP, with responsibility for Post Service Medical Review of all claims appealed in Preferred Blue, FEP, and The State HealthPlan. In this position, you will also provide medical support to Companion Life. The Vice President of Medical Affairs will serve as the Chair of the Medical Policy Committee, and the Co-Chair of the Gene Therapy Task Force along with the pharmacy leadership. We seek a strong physician leader, with managed care or payer experience, who will continue to build upon the foundation of enhanced transparency of medical policy that we’ve built. The ideal candidate will possess exceptional communication and relationship-building skills in a highly matrixed organization. Location: This position is full-time (40-hours/week) Monday-Friday ON-SITE at our 4101 Percival Road, Columbia, SC 29229 location.

Requirements

Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required.
10+ Years Broad clinical experience and a strong knowledge of quality assurance and risk management.
An active, unrestricted medical license from the United States and current board certification in a recognized specialty.

Nice To Haves

3-5 years of Managed care experience.
Masters in Business Administration, or Medical Management or Healthcare related field
Certified Physician Executive (CPE), Certified Care Physician Manager Certification (CCPM), and/or Certified in Health Care Quality and Management (CHCQM)
Preferred Executive level presentation skills.

Responsibilities

Provides direct physician support to all commercial lines of business including but not limited to Preferred Blue, FEP, State HealthPlan, and National Alliance utilization and case management functions including, but not limited to: pre-admission review, continued stat review, individual case management and individual surgical procedure certification.
Supervises the activities of the Physician Advisors.
Provides oversight of Physician support team for National Alliance and Major Group client support.
Develops, maintains, and implements corporate medical claims payment policy.
Provides medical support to Preferred Blue/FEP Quality Programs to facilitate compliance with all SC Department of Insurance regulations and/or NAIC recommended standards, and to ensure maintenance of a total quality management program that meets or exceeds the requirements for accreditation of Preferred Blue and FEP by national quality associations (i.e., URAC or NCQA).
Assesses reports and information generated by Utilization Management, Case Management, Provider Profiling, Provider Services, and other internal functions to determine the extent and evaluate the impact of underutilization and overutilization of important aspects of care and service.
Serves as consultant to provide input regarding complex case management in Preferred Blue.
Supervises the Activities of the Post Service Medical Management area which includes the development of claims payment policy and the review of post service claims review and appeals.
Assists in the Credentialing of providers for the BCBSSC networks.
Reviews all problems files.
Participates as a voting member of CBA Medical Advisory Committee.
Provides direct physician support to Underwriting, Corporate Audit and provides medical consulting support to Companion Life on request.
Serves as a corporate liaison for Blue Cross Blue Shield of SC as a member of various external organizations.
Directs the performance of surveys, audits, outcome analyses and reviews those issues identified by the prioritization process, gathering the results of these activities, and writing reports concerning the outcomes.
Facilitates linkage between quality improvement and other management functions within the Plan, e.g., network modifications, benefits redesign, medical management systems, proactive feedback to providers, patient education programs, etc.
Serves as Chairperson of the Quality Medical Advisory Committee (QMAC) responsible for assessment of functions and development and implementation of standards in the following areas: Quality Improvement, Utilization Management, Case Management, Credentialing/Re-credentialing, Members’ Right and Responsibilities, Preventive Health Services and Medical Records.
Completes review of all providers applying for network participation to ensure the quality of providers accepted and ensure qualified clinicians are accountable to the organization for decisions affecting our members.