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 required
- 5 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 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
Number of Openings Available:
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Equal Opportunity Employer Statement
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.
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.
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