Job Description

The Medical Director brings a unique set of knowledge and skills to the business of Blue Cross North Carolina and frequently serves as an interface between the company and physicians, providers, employer and community groups, and members as needed. Utilizes clinical knowledge and experience to support value-based strategies, clinical operations and our organizational pursuit of high quality and cost-effective care for members.
Hiring range for this position: $200,000 - $212,000

What You'll Do

The application of a Medical Director's knowledge and clinical skills will vary across the Health Care division, dependent on focus areas identified by the business areas supported.

Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan membersConducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of careEvaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial processEducates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource managementFacilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirementsReviews quality referred issues, focused reviews and recommends corrective actionsDevelops and implements plan medical policiesSupports population healthMonitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of careEnsures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical careEnsures that medical protocols and rules of conduct for plan medical personnel are followedProvides clinical expertise in support for quality improvement, sales, account, technology, investment and community engagement activitiesWorks with Contracting Department in contract negotiation

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Leadership Skills:

Project planning and management

Core Skills:

StrategyDevelops, collaborates and/or drives strategy and approach for varied Health Care and/or organizational initiatives (i.e. sales management strategies, behavioral health strategies, new health care delivery strategies)OperationsMedical reimbursement and policyCare management (utilization management, case management, PA, appeals)Healthcare programs (disease management, Moonshots)Network support (Credentialing)Quality model design and analysisPartnershipDevelop strategic partnerships with internal business partners and external clients to support value-based agreements and drive better consumer and provider experience.Takes a lead role in outreach and relationship building across the community (i.e. providers, health systems, community partners, members, etc).Evaluate and manage new and/or existing vendors and solution partners to align to BCNC’s strategic directionOngoing provider engagement functionsData gathering, management and analysisEvaluate clinical and other data to identify opportunities for improvement in health outcomes and financial performanceDiscuss data and performance with providers, employers, accreditors and regulators as needed.CommunicationsRepresent BCNC through delivery of presentations, speaking engagements and leadership of advisory groups with external audiences related to health care transformation and BCNC’s initiatives.Publish high impact content focused on improving accessibility, quality and affordability.InnovationPayment model designIdentify market trends that should influence key investments (new technologies, best practices).Evaluation of investment/partnership opportunities

What You'll Bring (Hiring Requirements)

MD or DO from an accredited medical school and completion of residency training program5+ years of experience in related fieldCurrent North Carolina medical license or willing to apply/obtain by start dateBoard certification in ABMS/AOA recognized clinical specialty

The Following Specialties are Preferred

Pain ManagementOrthopedicFamily Practice

Salary Range

$146,500.00 - $278,200.00