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:
- 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.
- 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.
- 5 years - Clinical experience required
- 5 years - Healthcare administration, including UM experience required
- 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:
- Preference for previous UM, prior authorization and/or appeals review experience
- Experience with pharmacy preferred
Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver's license, auto insurance compliance with minimum liability requirements; as defined in the "Use of Non BCBST-Owned Vehicle" Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR).
*The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.