$100K - $150K(Ladders Estimates)
Provide medical leadership and clinical expertise for various areas and functions across the enterprise including utilization management, care management, quality management, pharmacy, credentialing, provider affairs, customer service, claims editing and compliance.
Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.
Responsible for supporting various departments and lines of business within the enterprise such as: HMO, Medicare, Commercial, Senior Health Services (Medicare), Utilization Management, Clinical Management, Pharmacy, and Care Management/Case Management. Provides clinical program leadership and implements, develops and approves policies within the recognized area of responsibility.
Advise and collaborate with colleagues, directors, and leadership in the development of clinical programs.
Compliance with regulatory and accreditation organizations.
Support Senior Health Services and Health Plan Business and other key business units.
Provide high-level clinical program oversight. Provide clinical support and participate in utilization management, quality management, and care management programs in the respective area and identify opportunities for improvement and efficiency. Provide clinical leadership for health promotion and education programs. Provide clinical leadership for claims editing department. Provide clinical/coding expertise for Corporate and Financial Investigations.
Impact the performance of BCBSM including short term effects on profitability, delivery of service and overall performance of assigned area; decisions may have long term effects. Perform clinical reviews and conduct peer to peers. Perform high dollar claims and complex case reviews. Identify larger scope business opportunities. Implement, develop and approve policies within recognized area of responsibility.
Develop strategic and operational plans for areas with input and review from executive leadership. Develop and implement operational plans that are aligned with the strategic initiatives for recognized area of responsibility using board technical knowledge. Execute strategic initiatives.
Assist in establishing corporate and regional programs to enhance the quality of care, reduce medical costs and achieve positive health outcomes. Assist CMO/VP and professional staff 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.
Impact quality, cost, service, and efficiency of area with significant impact on and accountability for performance of recognized area of responsibility. Comply with all regulatory, accreditation, security, and documentation standards.
Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality. Participate in inter-rater reliability activities. Participate in committees and workgroups to achieve department and corporate objectives.
Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy. Certification in Utilization Review preferred.
Current unrestricted state of Michigan doctor of medicine (M.D.) or doctor of osteopathy (D.O.) license.
Seven (7) years recent clinical experience in area of specialization plus utilization review experience. Strong teaching and communication skills.
Knowledge of BCBSM, providers and services and facilities.
Valid Through: 2019-10-17