Medical Director, Care Quality & Utilization (Hybrid)

Physician Pivot; Baltimore (MD); Hybrid; USD 226,000 - 419,000; Full time

Job summary

CareFirst BlueCross BlueShield seeks a Medical Director to oversee utilization review, care management and quality to ensure medical effectiveness of treatments. The role supports a hybrid work arrangement across the greater DC/ Baltimore metro area, with some home-based and CareFirst location activities as needed.

The incumbent will hold a Medical Degree, be board-certified, and licensed in MD/DC/VA, with extensive clinical experience and knowledge of managed care and regulatory standards.

Qualifications

• Medical Degree from an accredited medical school, completion of an American residency program required with postgraduate training.
• 11 years clinical practice experience.
• Current physician license to practice in Maryland, Washington DC, and VA without restriction; or current license to practice in Maryland and must be willing and able to obtain additional licenses in Washington DC and Virginia once hired, and Board Certification.
• Experience working in health plan or payer organization doing utilization review.

Responsibilities

• Ensure that the provision of health care service to the membership is compliant with the medical policies and standards. Participate in medical necessity reviews, including pre-service reviews, concurrent reviews of inpatient and post-acute care, and appeals.
• Oversees all activities of utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans.
• Provides clinical support for nursing staff, pharmacy, special investigations, legal, and public policy.
• Participates in key committees, including credentialing, quality improvement, technology assessment, medical policy, care management and others, as assigned, ensuring that the company meets all regulatory and accreditation standards.
• Serves as key resource for network physicians for peer to peer case discussion.

Skills

Managed care concepts

Care management coordination

HIPAA knowledge

Clinical best practices

Peer-to-peer discussions

Education

MD from an accredited medical school

American residency completion

Board Certification

Job description

CareFirst BlueCross BlueShield seeks a Medical Director to oversee utilization review, care management and quality to ensure medical effectiveness of treatments. The role supports a hybrid work arrangement across the greater DC/ Baltimore metro area, with some home-based and CareFirst location activities as needed.

The incumbent will hold a Medical Degree, be board-certified, and licensed in MD/DC/VA, with extensive clinical experience and knowledge of managed care and regulatory standards.