Medical Director Medical Policy, CMS/MA

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 (Hybrid)

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 />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

keywords: program,management,performance,education,experience,license,certification,skills,department preferences

Director

Competitive Total Compensation Package

Overview: <p><strong>Provides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.</strong></p>
Responsibilities: <ul> <li>Develop and maintain medical policy. Establish rationale for approving inquires and appeals.</li> <li>Assists with clinical research, writing documents, and documenting decisions.</li> <li>Provide utilization management for prior authorization procedures. Review cases and make decisions based on medical policy.</li> <li>Provide clinical support to various areas of the organization. Process requests for clarification, interpretation, or questions about policy or benefits. Review potential impacts of clinical matters.</li> <li>Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.</li> <li>Perform clinical reviews and conduct peer to peers.</li> <li>Participate in JUMP committee meetings.</li> </ul>
Requirements: <ul> <li>Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.</li> <li>Seven (7) years clinical practice experience.</li> <li>Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.</li> <li>Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.</li> <li>Proven leadership, problem solving, and the ability to manage multiple priorities.</li> <li>Strong teaching and communication skills.&nbsp;</li> <li>Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.</li> <li>Demonstrated skill with Microsoft Office Suite and web-based programs.</li> <li>Understanding of health plan functions related to utilization, care, and quality management.</li> <li> <div>Other related skills and/or abilities may be required to perform this job.</div> </li> </ul> <div>&nbsp;</div> <div><strong>Department Summary / Preferences:</strong></div> <ul> <li>Medicare Experience is preferred.</li> <li>Medical Policy Experience is a plus.</li> </ul>