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 (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: position summary,leadership,assist,review,ed,experience,license,certification,knowledge,skills

Director

Competitive Total Compensation Package

Overview: <p><strong>Provide clinical expertise across the enterprise for various functions.&nbsp; Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.&nbsp; Advise and collaborate in the development of clinical programs.</strong></p>
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>