Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, disease management, quality management, pharmacy management, post service reviews, provider education, support for provider relations issues, and clinical transformation. The Medical Director is accountable for a personal caseload of daily medical management activities and contributing to operational effectiveness of the medical management program.
Responsibilities:
- Support all lines of business which includes Commercial and Government Programs.
- Collaborate with value based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable. Supports sales teams as assigned by region.
- Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable. Consult with/support case management to determine best course for members, assist with PG and address issues.
- Develops and maintains effective collaborative relationships with providers in assigned geographic areas. This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers.
- May provide input into provider credentialing, profiling and communication initiatives.
- Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management.
- Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix. Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region.
- Assists with assessment of network capabilities by region and collaborates with network management, contracting and value based teams in addressing network gaps.
- Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas.
- Participates in Committee activities as assigned.
- Assist with coverage across functional MD teams, as needed, including participation in calls for all areas.
- Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team.
- Works with legal and mandate team to support Horizon's compliance with the NJ Department of banking and insurance (DOBI).
- Backup chair for committees with internal and external stakeholders.
Qualifications:
- Requires Board Certification in an American Board of Medicine recognized specialty and current unrestricted MD or DO license to practice medicine.
- Requires 5-7 years clinical experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management.
- Proficiency working with Tableau or similar software required.
- Proficiency also required working with a Windows based environment including MS Office products.
- Continuous Improvement experience preferred.
Travel % (If Applicable):
- The position requires access to a car and the ability to travel for meetings with physicians, hospitals and ancillary providers as required.
Salary Range:
$207,800 - $289,170
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
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