POSITION PURPOSEPromote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. Reviews treatment procedures and services to ensure that they are within established guidelines or supported by generally accepted medical evidence when formal guidelines do not exist. To provide direction to operations as applicable, including utilization activities including but not limited to Utilization Management, Case Management and Disease Management, Population Health and Wellness. Facilitates all physician and provider committees as needed. Provides advice on external contractual benefit issues.
NATURE AND SCOPE- This role does not manage people
- This role reports to this job: SENIOR MEDICAL DIRECTOR (MGR)
- Necessary Contacts: department Managers, Authorization, Utilization Management, Case Management, Disease Management, Compliance personnel, and other employees as indicated, Licensed Doctors of Medicine (Physicians), Hospitals, and other healthcare providers, Parish and state medical agencies and societies as needed, Accreditation and governmental entities' personnel as needed.
QUALIFICATIONSEducation- Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) required
- Must be qualified to render a clinical opinion about the medical condition, procedures and treatment under review.
Work Experience- 7 years of clinical practice experience is required
- 3 years of post graduate experience with direct patient care required; prefer 5 years of experience.
- Administrative experience in a health plan and/or a working knowledge of the insurance industry preferred
- Prior detailed experience in either utilization, case or disease management in a hospital or health plan setting preferred, along with a positive history of providing consultative efforts concerning medical and legal issues are preferred
- Experience with external accreditation bodies; JCAHO, URAC, or NCQA preferred
- Medicare Advantage experience is preferred
Skills and Abilities- Excellent communication, presentation, interpersonal and human relation skills are required.
- Microsoft Office software Word, Excel, Outlook, PowerPoint proficiency required.
- The position requires availability for travel and working extended hours.
Licenses and Certifications- Current, license to practice medicine in Louisiana of the type and scope that permits application of clinical judgement in consideration of an individual member's clinical needs to render a utilization review determination
- License must be unrestricted; or if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional's ability to fulfill the roles and responsibilities of a reviewer
- Must have the ability to obtain a medical licensure for the state of Louisiana required
- Board certification in a specialty recognized by ABMS required
ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS- Fulfills medical director duties as appropriate which include but are not limited to: peer reviews, case reviews, completion of inter-rater reliability case reviews annually, active participation in training activities, provision of documentation to support compliance with annual licensure requirements, claims review to determine proper resolution, maintaining a working knowledge of company policies and procedures.
- Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims related issues.
- Reviews, provides medical expertise and reports on activities related to utilization, case, and disease management, Authorizations, Compliance, Network Administration, Southern National Life (SNL), Legal and other departments requiring guidance.
- Participates in and supports internal operations such as quality assurance efforts, the BCBSLA Quality Improvement Plan, accreditation/URAC related activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives.
- Participates in and/or acts as a voting member on committees which may include but is not limited to: Pharmacy & Therapeutics, Credentialing and Second Level Administrative Appeals as directed by the Senior Medical Director.
- Completes required training activities in a timely manner.
- Complies with Licensure & Board Certification requirements. Reports adverse changes in licensure, Board Certification to the Senior Medical Director within one business day of notification.
- Complies with all laws and regulations associated with duties and responsibilities.
- Reviews requests for services for prior authorization, concurrent stay and retro review based on commercial criteria, Medical Policies application of member contract benefits, or if formal guidelines do not exist, makes determinations of medical necessity supported by generally accepted medical evidence.
- - Consults with initial clinical reviewers as needed.
- - In cases of non-certification determinations, conducts peer clinical reviews with attending physicians or orders providers within one business day of a request while in compliance with accreditation standards.
- - When the clinical peer reviewer making the initial determination is not available, does peer to peer in his/her place.
- - If peer to peer conversation does not result in certification, notifies provider of consumer's right to initial and appeal and the related procedure.
- Performs medical or administrative appeals as needed based on medical policy, benefit language or standard of care.
Additional Accountabilities and Essential FunctionsThe Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
- Perform other job-related duties as assigned, within your scope of responsibilities.
- Job duties are performed in a normal and clean office environment with normal noise levels.
- Work is predominately done while standing or sitting.
- The ability to comprehend, document, calculate, visualize, and analyze are required.
