Senior Medical Director, Care Management & Utilization

Florida Blue; Jacksonville (FL); On-site; USD 224,000 - 364,000; Full time

Benefits offered by this job

Comprehensive benefits

Employer retirement match

Paid time off & holidays

Wellness program

Job summary

Florida Blue is seeking a Medical Director to lead utilization management reviews across Pre-service, Post-service, and Concurrent Review, with peer-to-peer discussions with physicians and collaboration with Case Managers to ensure timely, compliant medical necessity decisions.

The role requires a Florida medical license, ABMS board certification or eligibility, at least 5 years of clinical experience, and strong communication skills in a fast-paced environment.

Qualifications

• Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine.
• Board Certification or Board eligibility by American Board of Medical Specialties or equivalent.
• 5+ years of clinical experience.
• Experience working in a dynamic, fast-paced environment.
• Experience working both independently and in a team environment.
• Exceptional verbal and written communication

Responsibilities

• Perform UM reviews including Pre-service, Post-service, Concurrent Review and Appeals.
• Discuss cases with physician providers (Peer to Peer).
• Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests.
• Collaborate with Case Managers to provide support and guidance on cases needing physician assistance.
• Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review.
• Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary.
• As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies.
• Participate in the development and review of Medical and Pharmacy policies as assigned.
• Support the organization as a subject matter expert.
• Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy.
• Perform other duties as assigned and needed by the organization

Skills

Communication skills

Education

MD or DO license

ABMS board certification or eligibility

Job description

Florida Blue is seeking a Medical Director to lead utilization management reviews across Pre-service, Post-service, and Concurrent Review, with peer-to-peer discussions with physicians and collaboration with Case Managers to ensure timely, compliant medical necessity decisions.

The role requires a Florida medical license, ABMS board certification or eligibility, at least 5 years of clinical experience, and strong communication skills in a fast-paced environment.