Medicare Advantage Medical Director

6 days ago

Apply Now

Receive Emails with Similar Jobs

BlueCross BlueShield of Tennessee

WebsiteLinkedInAll Job Openings

Health • Wellness • Fitness • Insurance • Customer Service

5001 - 10000

Description

• 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.

Requirements

• Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. • 5 years - Clinical experience required • 5 years - Healthcare administration and/or UM experience preferred • Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists. • Ability to conceive and deliver innovative solutions. • Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability. • Outstanding negotiation, presentation, and facilitation skills. • Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint). • Ability to interpret and explain complex government policies. • Knowledge of Medicare programs.