Medical Director Medical Policy, CMS/MA

Blue Cross Blue Shield of Michigan; Detroit (MI); On-site; USD 160,000 - 190,000; Full time

Job summary

Blue Cross Blue Shield of Michigan seeks a physician-lead to drive clinical program leadership, develop and approve medical policies, and support utilization management across the organization. The role requires MD/DO licensure in Michigan and board certification or active pursuit of specialty certification.

Responsibilities include leading policy development, evaluating inquiries and appeals, and serving as a clinical expert to cross-functional teams.

Qualifications

• Must hold MD or DO license from a state medical board.
• Board certification or eligibility in a specialty recognized by the ABMS/ABO is required or in progress.
• Proven leadership, problem-solving, and ability to manage multiple priorities.

Responsibilities

• Provide clinical program leadership and develop, implement and approve policies within the designated area.
• Develop and maintain medical policy; establish rationale for approving inquiries and appeals.
• Assist with clinical research, documentation, and decision records.

Skills

Leadership

Problem solving

Communication skills

Teaching

Cross-functional collaboration

Microsoft Office

Education

MD/DO

Tools

Microsoft Office

Web-based programs

Job description

Provides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.

Develop and maintain medical policy. Establish rationale for approving inquires and appeals.

Assists with clinical research, writing documents, and documenting decisions.

Provide utilization management for prior authorization procedures. Review cases and make decisions based on medical policy.

Provide clinical support to various areas of the organization. Process requests for clarification, interpretation, or questions about policy or benefits. Review potential impacts of clinical matters.

Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.

Perform clinical reviews and conduct peer to peers.

Participate in JUMP committee meetings.

"Qualifications"

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.

Seven (7) years clinical practice experience.

Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.

Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.

Proven leadership, problem solving, and the ability to manage multiple priorities.

Strong teaching and communication skills.

Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.

Demonstrated skill with Microsoft Office Suite and web-based programs.

Understanding of health plan functions related to utilization, care, and quality management.

Other related skills and/or abilities may be required to perform this job.

Department Summary / Preferences:

Medicare Experience is preferred.

Medical Policy Experience is a plus.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

Job Info

• Job Identification 15009
• Legal Employer Blue Cross Blue Shield of Michigan Mutual Insurance Company