About the Role
The Senior Medical Director supporting the Commercial Business Unit (CBU) serves as the primary physician leader and clinical liaison for CBU clinical engagements. The role provides clinical credibility, timely medical expertise, and actionable recommendations that help make healthcare work for CBU’s customers while strengthening relationships, supporting client retention and growth, and translating complex clinical topics into practical, client-ready discussions.
What You'll Do
Client and Market-Facing Clinical Leadership
- Serve as the Medical Director attendee and presenter for the Board, annual and biannual performance meetings with Horizon’s CBU customers, including national account and ASO clients.
- Participate in finalist, broker, prospective clients, existingcustomersand internal account team preparation and presentations.
- Build andmaintainproductive relationships with external Medical DirectorsrepresentingCBU customers, clinical teams working for brokers and consultants, and NJ DOBI contacts on clinical issues.
- Use client profiles and account background materials to tailor clinical discussion,anticipatequestions, and present complex clinical information in a clear, client-friendly manner.
- Attend customer status calls with Account Managers or Account Executives when clinicalexpertiseis needed.
Clinical Escalations, Appeals and Performance Guarantees
- Provide clinicalexpertiseon escalated customer inquiries and appeals, supporting the committed three-business-day turnaround expectation for clinical escalations.
- Speak directly with network providers, asappropriate, to address authorization-related escalations in support of CBU’s customers.
- Provide clinicalexpertiserelated to audits and performance guarantees.
Medical Policy, Coding and Cost Optimization
- Act as the liaison between the Medical Policy Committee and the CBU teams on medical policy changes that couldimpactCBU clients.
- Bring medical policy-related concerns voiced by CBU clients to theappropriate committeeor forum for review and resolution.
- Support clinical coding updates and coding changes requested by, orimpacting, CBU clients.
- Develop,participateinand communicate medical cost optimization programs thatimpactCBU clients.
- Provide recommendations for internal process updates based on customer feedback and recurring clinical issues.
Cross-Functional Resource Planning and Meeting Support
- Partner with CBU Account Executives, Pharmacy, Analytics, Care Management, and administrative support to coordinate annual wrap-up,finalistand client-facing meeting support.
- Coordinate with Analytics on outcomes reporting needed for client meetings.
- Partner with Nurse Case Managers to complete interdisciplinary rounds for clients’ with performance guarantees related to case management activity.
Program, Audit and Vendor Support
- Participate in and provide support for clinical audits of Horizon Care Navigator, Care Management Plus, High-Cost Claimant and related programs.
- Work closely with Horizon Care Navigator, Horizon Care Management Plus and Pharmacy teams toprovideclinical insight on cases.
- Clinically vet vendors requested by, or offered to, clients and provide recommendations on suitability, clinicalvalueand alignment with client needs.
- Hold accountability for budget management of specialty match spend onutilizationmanagement reviews for clients.
- Participate in association and consortium workgroups related to medical policy, quality, costcontainment, population health and sales, as applicable.
What You Bring
Education/Experience:
- MD or DO degree with active, unrestricted medical license; board certificationis stronglypreferred.
- Requires a minimum 5 years of clinical practice experience.
- Requires 3 years experience in managed care.
- Experience with account management, sales, analytics, pharmacy, utilization or care management, medical policy, broker/consultant,or regulatory-facing teams is preferred.
- Strong executive presence and communication skills, with ability torepresentHorizon in client, finalist, broker,consultantand external Medical Director discussions.
- Understanding of client needs, performance guarantees, clinical escalations, medical cost trends, high-cost claimant dynamics,utilizationmanagementand vendor evaluation preferred.
Additional licensing, certifications, registrations:
- Requires American Board of Medical Specialties (ABMS) board certification.
Knowledge:
- Significant clinical leadership experience in managed care, health plan, payer, employer group, populationhealthor related healthcare environment.
- Demonstrated ability to communicate complex clinical,utilizationmanagement, medical policy,pharmacyand cost containment topics to non-clinical audiences.
- Requires proficiency working with a Windows based environment including MS Office products.
- Requires knowledge of clinical operations within a managed care organization.
- Requires knowledge of Commercial health insurance products
Skills and Abilities:
- Clinical judgment and credibility
- Client-centric communication and relationship management
- Enterprise collaboration and cross-functional influence
- Strategic thinking with practical execution discipline
- Data-informed decision making and resource planning
- Accountability,responsivenessand attention to commitments
- Ability to simplify complexity for executive,clientand account team audiences
- Be adept at influencing and challenging senior management and staff.
- Manage, and lead through influence, in a highly matrixed environment.
- Must be able to present and interact with senior leadership or clients as necessary.
- Must be able to tailor communication and messages to diverse audiences.
- Advocates for the organization, inspiring confidence among peers regarding reliability and capability, inspiring senior leadership expectations on potential for outstanding outcomes and achievements.
- Develop Horizon BCBSNJ staff’s competences related to medical cost optimization (MCO) and executive decision-making skills.
- Requires the ability to exercise independent judgment in making decisions.
- Requires the ability to interpret and apply state and federal regulations, hospital and provider contracts and medical policy to provide guidance related to MCO.
- Must have effective verbal and written communication and presentation skills and demonstrate the ability to work well within a team.
- Requires a proven ability to innovative, be goal oriented, possess strong critical thinking skills, and exercise sound judgment.
- Requires experience with utilization management, quality, payment integrity, case management, and/or medical policy.
- Requires broad clinical skills to understand medical issues.
Salary Range:
$240,200 - $334,110
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
