Head of Medical Cost Optimization

Horizon Blue Cross Blue Shield of New Jersey; The Ironbound (NJ); On-site; USD 240,000 - 334,000; Full time

Benefits offered by this job

Health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Volunteer time off

Tuition reimbursement

Job summary

Horizon BCBSNJ is seeking a Senior Medical Director for Affordability to lead medical cost optimization efforts and guide the clinical direction of MCO programs. This physician leader will partner with strategy and execution teams to identify opportunities, support provider and client inquiries, and ensure high-quality program outcomes.

Travel within NJ/NY/PA is required; the role offers a comprehensive benefits package and opportunities to influence affordability and care quality across Horizon

Qualifications

• Requires an MD or DO with an unrestricted license.
• Requires American Board of Medical Specialties (ABMS) board certification.
• Requires a minimum 5 years of clinical practice experience.
• Requires a minimum of 3 years of experience in managed care/medical management.
• Requires proficiency working with a Windows based environment including MS Office products.
• Requires 3 years of management experience.
• Requires knowledge of clinical operations within a managed care organization.
• Requires experience with utilization management, quality, payment integrity, case management, and/or medical policy.
• Requires knowledge of medical cost optimization.
• Requires broad clinical skills to understand medical issues.

Responsibilities

• Define a multi-year Medical Cost Optimization (MCO) strategy to drive affordability based on Horizon BCBSNJ experience, external data, competitive intelligence and implement this strategic vision, in collaboration with the MCO Strategy Lead.
• Partner with leadership across Horizon BCBSNJ business units to identify MCO opportunities and drive progress toward operational process improvements to ensure continual, measurable improvement of the quality, compliance, and speed of execution of MCO initiatives.
• Work collaboratively with the Clinical Analytics, Medical Economics, Finance, and other teams to source and validate the sizing and clinical efficacy of MCO business cases.
• Oversee tracking, analysis and reporting of data related to MCO to support the building of business cases, ROI analyses and measurement of progress toward MCO goals.
• Direct MCO work to guide opportunity and solution evaluation and prioritization using the principles of the MCO Committee governing framework to ensure achievement of multi-year affordability, quality, and clinical outcome targets.
• Facilitation of, and participation in, MCO Committee meetings.
• Facilitate prioritization of MCO solutions in need of funding through the CPLT and DRIVE processes.
• Partner with the Medical Cost Action Planning (MCAP), Finance and Actuary teams on tracking and reporting of enterprise MCO and MCAP performance.
• Communicate MCO strategy, activity and results across HNS and the enterprise.
• Communicate MCO efforts externally to network providers and their respective trade organizations.
• Educate Horizon BCBSNJ staff on MCO tools, strategies, and programs.
• Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

Skills

Executive leadership

Strategic planning

Communication skills

Influence in matrix org

Education

MD/DO license

ABMS board certification

5+ years clinical practice

3+ years managed care

MS Office

3+ years management

Managed care operations

Utilization management

Medical cost optimization

Broad clinical skills

Job description

Horizon BCBSNJ is seeking a Senior Medical Director for Affordability to lead medical cost optimization efforts and guide the clinical direction of MCO programs. This physician leader will partner with strategy and execution teams to identify opportunities, support provider and client inquiries, and ensure high-quality program outcomes.

Travel within NJ/NY/PA is required; the role offers a comprehensive benefits package and opportunities to influence affordability and care quality across Horizon