Job details
Job type full-time
Full job description
Additional locations: durham - 400 job description the lead medical director healthcare consulting provides day-to-day guidance, support and leadership to a group of medical directorsIs a clinical spokesperson and liaison between healthcare and sales, consults with our self-funded employer groups and supports the enterprise in all aspects of utilization, quality, and network managementProvides leadership and work coordination to team(s) within the health care divisionThe application of a lead medical director’s knowledge and clinical skills will vary across the health care division, dependent on focus areas identified by the business area supportedLeadership skills:
Leads healthcare interactions with sales to inform roadmap, goals, and timelines for high-cost claimant management, group reporting, new products, and investments
Supervises day to day activities of medical necessity review team with focus on commercial self-insured business
Leads review of aso high-cost claimants – manages escalation process and communication, brainstorming on difficult cases
Represents employer group perspective to internal workgroups, operations teams
Core skills:
Customer-facing presentations: client/broker meetings, webinars, conferences
Collaborates with healthcare consulting team to deliver data-driven insights and advise aso groups on cost-effective health programming
Strategy
O develops, 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)
Operations
O medical reimbursement and policy
O care management (utilization management, case management, pa, appeals)
O healthcare programs (disease management, behavioral health, alternative payment models)
O network support (credentialing)
O quality model design and analysis partnership
O develop strategic partnerships with internal business partners and external clients to support value-based agreements and drive better consumer and provider experience.
O takes a lead role in outreach and relationship building across the community (i.e., providers, health systems, community partners, members, etc.)
O evaluate and manage new and/or existing vendors and solution partners to align to bcnc’s strategic direction
Data gathering, management and analysis
O evaluate clinical and other data to identify opportunities for improvement in health outcomes and financial performance
O discuss data and performance with employers, brokers/consultants, providers, accreditors, and regulators as needed.
Communications
O develop content for quarterly “the doctor is in” e-letter and webinars (target: aso clients)
O represent bcnc through delivery of presentations, speaking engagements and leadership of advisory groups with external audiences related to health care transformation and bcnc’s initiatives.
O publish high impact content focused on improving accessibility, quality, and affordability.
Innovation
O payment model design
O identify market trends that should influence key investments (new technologies, best practices).
O evaluation of investment/partnership opportunities
Hiring requirements
Md or do from an accredited medical school
Mba or business degree is desirable
Completion of residency training program in abms/aoa recognized clinical specialty.
5 years of clinical experience following the completion of a residency program is required.
5 years of leadership experience.
2 years relevant experience outside of clinical practice is also required (i.ePrivate or government health plan, consulting house, academic roles, employee health programs, regulatory agency at state or federal level, etc.)
For some roles, a current north carolina medical license and/or board certification in abms/aoa recognized specialty is required.
Additional job description
More specifics for use in position descriptions or postings:
As a clinical spokesperson and liaison between healthcare and sales, the lead medical director for major markets consults with our self-funded employer groups (aso or administrative services only) to help them understand key cost drivers and opportunities for cost-effective healthcare programs or benefitsIdeal candidate possesses strong interpersonal and presentation skills and is comfortable delivering clinical content to non-clinical audiencesLeverages industry experience to deliver insights and advise groups on future healthcare trendsRole involves travel to client meetings with sales throughout the year.
In addition, this lead medical director oversees aso clinical team responsible for reviewing clinical trends, identifying and managing high-cost claimants, developing wellness offerings, and performing utilization managementThis individual also brings a unique set of knowledge and skills to the business of blue cross north carolina and may serve as an interface between the company and physicians, providers, employer and community groups, and members as neededUtilizes clinical knowledge and experience to support value-based strategies, clinical operations and our organizational pursuit of high quality and cost-effective care for members.
Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to plan members;
Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.
Ensures prior authorization and concurrent review requests are completed in timely manner and manages the denial process.
Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.
Facilitates conformance to medicare, medicaid, ncqa and other regulatory requirements.
Reviews quality referred issues, focused reviews and recommends corrective actions.
Develops and implements plan medical policies
Support population health
Attends or chairs committees as required such as credentialing, p&t and others as directed.
Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.
Ensures 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 care.
Ensures that medical protocols and rules of conduct for plan medical personnel are followed.
Provides clinical expertise in support for quality improvement, sales, account, technology, investment and community engagement activities.
Works with contracting department in contract negotiation as required.
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Job activity
Posted 16 days ago
