Medical Director Utilization Management

With more than 7,000 employees, we are the largest health insurance company in Michigan. We offer an exciting work environment with a diverse group of employees. Our goal is to make health insurance easier for our members. We want to transform the industry and become a resource that people can trust.

Detroit, MI

Blue Cross Blue Shield of Michigan

When you think of <a href="https://www.bcbsm.com/" target="_blank" rel="noopener noreferrer">Blue Cross Blue Shield of Michigan</a> for health insurance, you can know you&rsquo;re getting much more. We're a company founded on a tradition of affordable, quality health care for everyone, improving the present and investing in the future.&nbsp;<br /><br />We offer:<br />Plans for employers and individuals that meet today&rsquo;s needs, budgets and lifestyle<br />The largest network of doctors and hospitals in the state<br />Lower health care costs Higher quality health care<br />Award-winning diversity practices<br />Grants and programs that promote better health throughout Michigan<br /><strong><br />Mission:&nbsp;</strong>We commit to being our members&rsquo; trusted partner by providing affordable, innovative products that improve their care and health.<br /><br /><a href="http://www.bcbsm.com/index/about-us/our-company.html" target="_blank" rel="noopener noreferrer"><strong>Click here</strong></a> to learn more about our commitment to our Social Mission, view company updates and reviews, and view our awards &amp; accolades.<br /><br />For Application Timeline &amp; Selection Process:&nbsp;<a href="https://s3.amazonaws.com/data.vizirecruiter.com/Images/BCBSMCareers+-+Quick+Reference+Guide.pdf" target="_blank" rel="noopener noreferrer">Click Here</a>. Learn more about your options as an external candidate. <a href="https://ejko.fa.us2.oraclecloud.com/hcmUI/CandidateExperience/en/sites/CX_3/requisitions" target="_blank" title="BCBSM" rel="noopener noreferrer">Click here</a> to view open positions. http://www.bcbsm.com

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Full-Time

Competitive Total Compensation Package

Overview: Provide clinical expertise across the enterprise for various functions. Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility. Advise and collaborate in the development of clinical programs.
Responsibilities: <ul> <li> <div>Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency.</div> </li> <li> <div>Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.</div> </li> <li> <div>Provide clinical leadership for health promotion and education programs and the claims editing department.</div> </li> <li> <div>Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes.</div> </li> <li> <div>Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.</div> </li> <li> <div>Perform clinical reviews and conduct peer to peers.</div> </li> <li> <div>Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality.</div> </li> <li> <div>Perform high dollar claims and complex case reviews.</div> </li> <li> <div>Participate in inter-rater reliability activities.</div> </li> <li> <div>Participate in committees and workgroups to achieve department and corporate objectives.</div> </li> </ul>
Requirements: <ul> <li> <div>Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.</div> </li> <li> <div>Seven (7) years clinical practice experience.</div> </li> <li> <div>Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management preferred.</div> </li> <li> <div>Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.</div> </li> <li> <div>Board certified or board eligible and working towards certification in a specialty approved by the</div> </li> <li> <div>American Board of Medical Specialists or the American Board of Osteopathy.</div> </li> <li> <div>Certification in Utilization Review and Health Care Quality &amp; Management is preferred.</div> </li> <li> <div>Ability to effectively communicate with external physicians and organizations.&nbsp;</div> </li> <li> <div>Proven leadership, problem solving, and the ability to manage multiple priorities.</div> </li> <li> <div>Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.</div> </li> <li> <div>Demonstrated skill with Microsoft Office Suite and web-based programs.</div> </li> <li> <div>Understanding of health plan functions related to utilization, care, and quality management as well as HEDIS/STARs and NCQA.&nbsp; Familiarity with CMS regulations and standards.</div> </li> <li> <div>Basic knowledge of evidence-based clinical decision support guidelines (InterQual).</div> </li> <li> <div>Basic knowledge of CPT coding and guidelines.</div> </li> <li> <div>Other related skills and/or abilities may be required to perform this job.</div> </li> </ul> <div id="gtx-trans" style="position: absolute; left: -144px; top: 26px;">&nbsp;</div>