Medicare Contractor Medical Director

033 Palmetto GBA; Columbia (SC); On-site; USD 220,000 - 320,000; Full time

Benefits offered by this job

Health insurance

401(k) plan with company match

Life Insurance

Paid Time Off

On-site facilities

Education assistance

Service recognition

National discounts

Job summary

Palmetto GBA, a BlueCross BlueShield of South Carolina subsidiary, seeks a Senior Medicare Contractor Medical Director to provide clinical and administrative oversight, analyze medical review data, and author or revise medical policies. The role emphasizes fraud, waste, and abuse awareness and collaboration with regulators and providers.

The position is full-time and on-site in Columbia, SC, requiring a U.S. citizen and board-certified physician with strong leadership and communication skills.

Qualifications

• Doctorate in a job-related field required.
• 5 years post graduate experience in direct patient care.
• Active state medical license and board certification.

Responsibilities

• Provide clinical and administrative oversight to medical staff.
• Analyze medical review utilization data and research procedures.
• Develop and revise medical policies with regulatory input.
• Educate staff and medical community on medical policy and program administration.
• Develop external relationships with medical community and contractors.
• Review physician practice patterns and unusual utilization data.
• Conduct research into new or controversial medical procedures.

Skills

Verbal communication

Written communication

Customer service

Organizational skills

Presentation skills

Leadership

Regulatory understanding

Education

Doctorate in a related field

Tools

Microsoft Office

Job description

Summary Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose

As member of the senior management team, the Medicare Contractor Medical Director provides clinical and administrative oversight to the medical staff, analyzes medical review utilization data, researches new medical procedures and technology, and acts as a resource to stakeholders, providers and internal staff on issues concerning medical policies. In this role, you will also write and revise medical policies. Our ideal candidate would bring an interest in fraud, waste, and abuse, as well as have experience in a specialized area of medicine.

Description Logistics

Palmetto GBA - one of BlueCross BlueShield's South Carolina subsidiary companies.

Location: This position is full-time (40-hours/week) Monday-Friday working ONSITE at our GPC location at 17 Technology Circle, Columbia, SC. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM.

Government Clearance: This position requires the ability to obtain a security clearance, which requires applicants to be a U.S. Citizen.

Sponsorship: This position is not eligible for sponsorship now or in the future.

What You’ll Do

• Support operations in the form of case review on both medical and regulatory matters.
• Develop claim adjudication criteria for situations requiring medical judgment.
• Provide input on issues and operational policies, processes, and procedures.
• Educate staff and medical community on various aspects of medical policy and program administration.
• Develop and update medical policy in consultation with appropriate regulatory personnel, medical consultants, and professional societies.
• Develop external relationships with the medical community and serve as a liaison between these entities and the contractors.
• Review physician and provider practice pattern analysis and other statistical data related to unusual medical service utilization.
• Conduct research into new or controversial medical procedures and technology.

To Qualify for This Position, You'll Need the Following

• Required Education: Doctorate in a job-related field.
• Required Experience: 5 years post graduate experience in direct patient care.
• Required Software and tools: Microsoft Office
• Required Skills and Abilities: Excellent verbal and written communication skills. Excellent customer service, organizational, and presentation skills. Good judgment skills. Proficiency in spelling, punctuation, and grammar. Ability to persuade, negotiate, or influence others. Ability to work as a team member as well as a leader. Knowledge of medical and utilization review techniques.
• Required Licenses and Certifications: Active state medical license and current board certification in a recognized specialty.

We Prefer That You Have the Following

• Medicare policy knowledge and experience.
• Interest in fraud, waste, and abuse.
• Experience working as a Cardiologist, Rheumatologist, or Internist.
• 10+ years of post-graduate experience in direct patient care.

Our Comprehensive Benefits Package Includes The Following

• Subsidized health plans
• dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information. Some states have required notifications. Here's more information.

About Palmetto GBA

Palmetto GBA is a healthcare service administrator and one of the nation’s largest providers of high-volume medical claims and transaction processing. We provide services and technology solutions to improve and streamline healthcare administration not only for government but also for corporate entities. We offer a wide range of services that require a diverse workforce and expansive areas of expertise from data analytics, administrative and workflow services to advanced systems. To help our associates succeed and reach their professional goal, we offer training classes and programs that help employees prepare for leadership positions and offer tuition assistance for education advancement. Palmetto GBA acknowledges associates’ hard work and dedication with awards and financial incentives.

Veterans Welcome

Palmetto GBA is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.