Medical Director, Utilization & Care Management Leader

Blue Cross Blue Shield of Michigan; Detroit (MI); On-site; USD 250,000 - 350,000; Full time

Job summary

Blue Cross Blue Shield of Michigan is seeking a Medical Director to provide enterprise-wide clinical expertise and policy interpretation, advising on the development of clinical programs. You will support utilization and quality management initiatives and collaborate with physicians to drive high-quality, cost-effective care.

The role requires an MD or DO with Michigan licensure and 7+ years of clinical practice; prior medical director experience is preferred.

Qualifications

• Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
• Seven (7) years clinical practice experience.
• Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management preferred.
• 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.
• Certification in Utilization Review and Health Care Quality & Management is preferred.
• Ability to effectively communicate with external physicians and organizations.
• Proven leadership, problem solving, and the ability to manage multiple priorities.
• Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.

Responsibilities

• Provide clinical expertise across the enterprise for various functions; interpret, recommend, and review corporate and medical policies.
• Support utilization management, quality management, and care management programs; identify opportunities for improvement and efficiency.
• Assist in design, development, implementation and assessment of disease state management and health enhancement programs.
• Provide clinical leadership for health promotion and the claims editing department.
• Establish corporate and regional programs to enhance quality of care and reduce medical costs.
• Serve as clinical resource and subject matter expert to staff.
• Perform clinical reviews and peer-to-peer discussions.
• Discuss medical policies and resource use with physicians in the BCBSM network.
• Perform high dollar claims and complex case reviews.
• Participate in inter-rater reliability activities and committees.

Skills

Leadership

Communication

Problem Solving

Project Management

Cross-functional Collaboration

CPT Guidelines

InterQual Guidelines

CMS Regulations

HEDIS/STARs Knowledge

Education

MD or DO medical degree

Unrestricted Michigan medical license

Tools

Microsoft Office Suite

Job description

Blue Cross Blue Shield of Michigan is seeking a Medical Director to provide enterprise-wide clinical expertise and policy interpretation, advising on the development of clinical programs. You will support utilization and quality management initiatives and collaborate with physicians to drive high-quality, cost-effective care.

The role requires an MD or DO with Michigan licensure and 7+ years of clinical practice; prior medical director experience is preferred.