Medical Director (Hybrid)

CareFirst, Inc.; Baltimore (MD); Hybrid; USD 226,000 - 419,000; Full time

Job summary

CareFirst BlueCross BlueShield in the Baltimore metro area seeks a Medical Director to oversee utilization review, care management and quality, directing medical effectiveness of proposed treatments and approving care plans. The role focuses on collaboration with nursing, pharmacy, legal and policy teams and leadership in committees to ensure regulatory compliance.

The position requires an MD with residency training and 11+ years of clinical practice, MD/DC/VA licensure or willingness to obtain

Qualifications

• Medical degree from an accredited medical school with American residency training.
• 11 years of clinical practice experience.
• Maryland/DC/VA physician license without restriction; or Maryland license with willingness to obtain DC/VA licenses; Board Certification.

Responsibilities

• Oversee utilization review, care management and quality to determine medical effectiveness of proposed treatments and approve care management plans.
• Provide clinical support for nursing staff, pharmacy, legal and public policy.
• Participate in key committees (credentialing, quality improvement, technology assessment, medical policy, care management) to meet regulatory and accreditation standards.
• Serve as a resource for network physicians for peer-to-peer case discussions.

Skills

Managed care concepts

Coordinating with physicians

HIPAA knowledge

Evidence-based guidelines

Education

Medical Degree

Tools

Job description

Resp & Qualifications

Purpose

The Medical Director oversees all activities of utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans. The critical responsibility will be the management of care delivery in a cost effective and quality assured system that will assist the organization to achieve its corporate mission of serving the health needs of members. We are looking for an experienced physician in the greater DC/Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week

Essential Functions

• 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 credentialling, 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.

Supervisory Responsibility

This position has no direct reports, however, may informally lead teams in a matrix environment.

Required Qualifications

Education Level: Medical Degree from an accredited medical school, completion of an American residency program required with postgraduate training.

Experience: 11 years clinical practice experience.

Licenses/Certifications: 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, andBoard Certification.

Preferred Qualifications

• Experience working in health plan or payer organization doing utilization review.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of managed care concepts and care management activities
• Skilled in coordinating and collaborating with physicians
• Knowledge of patient rights and laws relative to those rights, such as HIPAA
• Demonstrated application and knowledge of best health clinical practices
• Knowledge of principles, practices, evidence-based guidelines and standardized processes and procedures for evaluating medical support operations business practices

Salary Range: $225,760 - $419,067

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of theCompany to provide equal employment opportunities to allqualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS: The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship.