Job Responsibilities

Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST.Willingness to travel within the State of Tennessee and nationally.

Job Qualifications

Education

Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only.Based on business need, an unencumbered and unrestricted license in an alternative state may be substituted.

Experience

5 years - Clinical experience required5 years - Healthcare administration and/or UM experience preferred

Skills\Certifications

Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic SpecialistsAbility to conceive and deliver innovative solutionsAbility to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.Outstanding negotiation, presentation, and facilitation skillsProficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)Ability to interpret and explain complex government policiesKnowledge of Medicare programs

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis* will be automatically enrolled into the BCBST Driver Safety Program.   The employee will also be required to adhere to the guidelines set forth through the program.  This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the “Use of Non BCBST-Owned Vehicle” Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). *The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

Number of Openings Available:

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST is an Equal Opportunity employer (EEO), and all employees and applicants will be entitled to equal employment opportunities when employment decisions are made. BCBST will take affirmative action to recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Tobacco-Free Hiring Statement

To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test.  An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine  and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.

Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.