Regional Medical Director - Utilization & Policy

Horizon Blue Cross Blue Shield of New Jersey; Newark (NJ); On-site; USD 214,000 - 298,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Tuition Reimbursement

Paid Volunteer Time Off

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a Medical Director to lead medical management across New Jersey, providing leadership for utilization, care and disease management, quality and policy development. You will supervise daily medical management activities for a regional caseload, collaborate with provider networks, and support reimbursement policy efforts.

The role requires board certification and an active MD/DO license, with 5–7 years of clinical experience.

Qualifications

• Understanding of utilization and case management principles.
• Knowledge of health insurance payer business.
• Board Certification in a recognized medical specialty.
• Active unrestricted MD or DO license (NJ).

Responsibilities

• Support utilization and care management across NY and assigned regions.
• Consult with nurse reviewers on pre-authorization and post-service reviews.
• Analyze data and prepare monthly reports with performance insights.
• Collaborate with providers to improve quality and efficiency.

Skills

Utilization Management

Case Management

Quality Management

Tableau

MS Office

Tools

Tableau

MS Office

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a Medical Director to lead medical management across New Jersey, providing leadership for utilization, care and disease management, quality and policy development. You will supervise daily medical management activities for a regional caseload, collaborate with provider networks, and support reimbursement policy efforts.

The role requires board certification and an active MD/DO license, with 5–7 years of clinical experience.