Job Duties & Responsibilities
- Maintain working knowledge of all applicable managed programs, such as Governing CMS Rules and Regulations, Medicare Advantage Policies and Rules, Medicare Supplemental Policies and Rules, Medicare Part D Policies and Rules, Medicare Advantage MLR requirements, and the Annual Medicare Advantage Bid Process, as they apply to the administration of medical management services and Quality Management/ Quality Improvement Programs.
- Supervise medical directors who perform physician review as directed by the CMO
- Work closely with company analytic teams to coordinate, analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement activities to effectively manage utilization and cost trends.
- Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
- Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.
- Lead and serve on various committees appropriate to accomplishing the medical utilization, cost and quality objectives of BCBST.
- Support the Medical Management and Quality Programs through systematic education and information sharing.
- Other duties as assigned.
- MD or DO with unrestricted license to practice medicine in Tennessee.
- Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists.
- Advanced degree in health informatics and/or extensive experience with clinical data analysis preferred.
However, this requirement can be waived for jobs where the totality of the incumbent’s duties and responsibilities are restricted to the performance of administrative duties only.
- Minimum of 5 years clinical experience and 5 years of healthcare administration, including UM experience.
- Strong presentation, communication and negotiation skills.
- Ability to work effectively within a team environment
- Ability to interpret and explain complex government policies
- Willingness to travel within the State of Tennessee and nationally.
- Willingness to be innovative and take risks.
- Knowledge of personal computers and software programs, especially Microsoft Office, Outlook and Excel needed.
- Working knowledge of Care Advance and Facets preferred.
- Knowledge of Medicare programs is desirable
Job Specific Qualifications
- Previous experience with medical review work in a managed care environment preferred
- Experience with Medicare Part D preferred.