Medical Director, Utilization & Quality Improvement

Blue Cross Blue Shield of Michigan; Detroit (MI); On-site; USD 180,000 - 300,000; Full time

Job summary

Blue Cross Blue Shield of Michigan seeks an experienced physician leader to provide clinical expertise across the enterprise, interpret and review medical policies, and advise on the development of clinical programs.

The role supports utilization management, quality and care management programs, and leads high-dollar/complex case reviews while collaborating with physicians and staff to improve care quality and reduce costs.

Qualifications

• Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
• Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management 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.
• Demonstrated skill with Microsoft Office Suite and web-based programs.
• Understanding of health plan functions related to utilization, care, and quality management as well as HEDIS/STARs and NCQA. Familiarity with CMS regulations and standards.
• Basic knowledge of evidence-based clinical decision support guidelines (InterQual).
• Basic knowledge of CPT coding and guidelines.

Responsibilities

• Provide clinical expertise across the enterprise for various functions. Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.
• Advise and collaborate in the development of clinical programs.
• Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency.
• Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.
• Provide clinical leadership for health promotion and education programs and the claims editing department.
• Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes.
• Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
• Perform clinical reviews and conduct peer to peers.
• Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality.
• Perform high dollar claims and complex case reviews.
• Participate in inter-rater reliability activities.
• Participate in committees and workgroups to achieve department and corporate objectives.

Job description

Blue Cross Blue Shield of Michigan seeks an experienced physician leader to provide clinical expertise across the enterprise, interpret and review medical policies, and advise on the development of clinical programs.

The role supports utilization management, quality and care management programs, and leads high-dollar/complex case reviews while collaborating with physicians and staff to improve care quality and reduce costs.