Medical Director - Care Management in Chattanooga, TN

$100K - $150K(Ladders Estimates)

BlueCross BlueShield of South Carolina   •  

Chattanooga, TN 37402

Industry: Finance & Insurance

  •  

5 - 7 years

Posted 53 days ago

Provides clinical leadership and serves as an internal medical consultant to various divisions and committees to support the development, implementation and monitoring of medical management and quality improvement activities.Job Description:

Job Responsibilities

  • 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.
  • Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.
  • Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.
  • Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST.
  • Willingness to travel within the State of Tennessee and nationally.

Job Qualifications

Education

  • Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only.

Experience

  • 5 years - Clinical experience required
  • 5 years - Healthcare administration, including UM experience required

Skills\Certifications

  • Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists
  • Ability to conceive and deliver innovative solutions
  • Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.
  • Outstanding negotiation, presentation, and facilitation skills
  • Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)
  • Ability to interpret and explain complex government policies
  • Knowledge of Medicare programs

Job Specific Requirements:

Previous experience in the Internal Medicine or Family Practice disciple or as Hospitalist or Orthopedist preferred.

Valid Through: 2019-10-18