Senior Medical Director (Palmetto GBA)

BlueCross BlueShield of South Carolina; Oregon (WI); Remote; USD 222,000 - 447,000; Full time

Job summary

A leading health insurance provider is looking for a Medical Review Lead to oversee the development of medical review strategies and ensure the integrity of claims payments. Candidates should possess a doctorate and have a minimum of 10 years of relevant experience, along with strong analytical, leadership, and communication skills. This role is flexible, offering both remote and on-site options in Columbia, SC.

Benefits

Subsidized health plans

401k retirement savings plan with company match

Paid Time Off (PTO)

Education Assistance

Life Insurance

On-site cafeterias and fitness centers

Qualifications

• 10 years of experience in a relevant field.
• Demonstrated effectiveness in informing strategic decisions.
• Knowledge of medical and utilization review techniques.

Responsibilities

• Oversee development of Medical Review strategy.
• Direct Local Coverage Determinations (LCDs).
• Collaborate with stakeholders to improve processes.

Skills

Analytical skills

Communication (verbal and written)

Critical thinking

Organizational skills

Adaptability

Team leadership

Decision-making

Education

Doctorate in a job related field

Tools

Microsoft Office Software

Job description

Summary

Position Purpose: As a member of the leadership team, you will oversee and direct the synthesis of data and clinical knowledge in the development of information that is used to inform the detection, correction and prevention of claims payment errors. You will lead a Medical Review team in the development and implementation of an efficient and effective medical review strategy which includes the integration of policy and education, that optimizes critical medical review cycle times. In this role you will also serve as the Medical Review liaison between internal and external stakeholders.

Logistics

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

Location

This position is full-time (40-hours/week) Monday-Friday. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. You may be required to travel between buildings. This role is REMOTE in the US or ONSITE at our Government Programs Building at 17 Technology Circle, Columbia, SC in the United States.

What You'll Do

• Oversees the development, implementation and communication of Medical Review strategy and the optimization of critical Medical Review cycle times.
• Directs and oversees the development of effective Local Coverage Determinations (LCDs) aimed at addressing identified or preventing potential widespread claims payment errors.
• Collaborates with internal stakeholders to address priority areas identified in the Medical Review Strategy.
• Assists the VP to engage external stakeholders in the efforts to disseminate information and implement process improvements in support of the Medical Review Strategy.

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

• Required Education: Doctorate in a job related field.
• Required Experience:
  • 10 years experience.
• Required Skills and Abilities:
  • Demonstrated effectiveness in the creation of information that successfully informs strategic and management decisions.
  • Demonstrated knowledge/experience in directing and participating in the development of medical coverage policy.
  • Strong analytical, judgment, presentation, critical thinking, organizational and planning skills.
  • Ability to adapt to ever changing business environment/priorities.
  • Working knowledge of statistical concepts, population statistical and analysis methods.
  • Excellent communication (verbal and written) skills.
  • Demonstrated medical systems knowledge/experience.
  • Ability to exercise good judgment with capacity of working/communicating with diverse range of individuals (clinicians, suppliers and all levels of employees).
  • Ability to work in a very dynamic environment with minimal supervision.
  • Ability to work as a leader as well as a team member.
  • Knowledge of medical and utilization review techniques.
  • Ability to comprehend government regulatory and political structures.

Required Software: Microsoft Office Software

Required License and Certificate: If Medical Doctor (MD) or Doctor of Osteopathy (DO), active state medical license and current board certification in a recognized specialty.

We Prefer That You Have the Following

• Board certified for at least 3 years
• Experience working with physician groups, beneficiary organizations, and/or congressional offices is preferred.
• Prior clinical practice as an attending physician.
• MBA or business degree
• Strong business acumen
• Geriatrician or experience with geriatric population
• Work experience in the health insurance industry, a utilization review firm, or another health care claims processing organization in a role that involved developing coverage or medical necessity policies and guidelines.
• Extensive knowledge of the Medicare program, particularly the coverage and payment rules.

Benefits

Our comprehensive benefits package includes the following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• 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.

What to Expect Next

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.

Pay Range Information

Pay Range: Range Minimum $222,723.00; Range Midpoint $334,548.00; Range Maximum $446,373.00

Pay Transparency Statement

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Equal Employment Opportunity

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. 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 participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

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.

Here's more information about state notifications and related policies.