Medical Director - Medicare Advantage

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.Residency in or relocation to Louisiana is preferred for all positions.POSITION PURPOSEPromote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. Reviews treatment procedures and services to ensure that they are within established guidelines or supported by generally accepted medical evidence when formal guidelines do not exist. To provide direction to operations as applicable, including utilization activities including but not limited to Utilization Management, Case Management and Disease Management, Population Health and Wellness. Facilitates all physician and provider committees as needed. Provides advice on external contractual benefit issues.NATURE AND SCOPEThis role does not manage peopleThis role reports to this job: SENIOR MEDICAL DIRECTOR (MGR)Necessary Contacts: department Managers, Authorization, Utilization Management, Case Management, Disease Management, Compliance personnel, and other employees as indicated, Licensed Doctors of Medicine (Physicians), Hospitals, and other healthcare providers, Parish and state medical agencies and societies as needed, Accreditation and governmental entities’ personnel as needed.QUALIFICATIONSEducationDoctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) requiredMust be qualified to render a clinical opinion about the medical condition, procedures and treatment under review.Work Experience7 years of clinical practice experience is required3 years of post graduate experience with direct patient care required; prefer 5 years of experience.Administrative experience in a health plan and/or a working knowledge of the insurance industry preferredPrior detailed experience in either utilization, case or disease management in a hospital or health plan setting preferred, along with a positive history of providing consultative efforts concerning medical and legal issues are preferredExperience with external accreditation bodies; JCAHO, URAC, or NCQA preferredMedicare Advantage experience is preferredSkills and AbilitiesExcellent communication, presentation, interpersonal and human relation skills are required.Microsoft Office software Word, Excel, Outlook, PowerPoint proficiency required.The position requires availability for travel and working extended hours.Licenses and CertificationsCurrent, license to practice medicine in Louisiana of the type and scope that permits application of clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determinationLicense must be unrestricted; or if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewerMust have the ability to obtain a medical licensure for the state of Louisiana requiredBoard certification in a specialty recognized by ABMS requiredACCOUNTABILITIES AND ESSENTIAL FUNCTIONSFulfills medical director duties as appropriate which include but are not limited to: peer reviews, case reviews, completion of inter-rater reliability case reviews annually, active participation in training activities, provision of documentation to support compliance with annual licensure requirements, claims review to determine proper resolution, maintaining a working knowledge of company policies and procedures.Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims related issues.Reviews, provides medical expertise and reports on activities related to utilization, case, and disease management, Authorizations, Compliance, Network Administration, Southern National Life (SNL), Legal and other departments requiring guidance.Participates in and supports internal operations such as quality assurance efforts, the BCBSLA Quality Improvement Plan, accreditation/URAC related activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives.Participates in and/or acts as a voting member on committees which may include but is not limited to: Pharmacy & Therapeutics, Credentialing and Second Level Administrative Appeals as directed by the Senior Medical Director.Completes required training activities in a timely manner.Complies with Licensure & Board Certification requirements. Reports adverse changes in licensure, Board Certification to the Senior Medical Director within one business day of notification.Complies with all laws and regulations associated with duties and responsibilities.Reviews requests for services for prior authorization, concurrent stay and retro review based on commercial criteria, Medical Policies application of member contract benefits, or if formal guidelines do not exist, makes determinations of medical necessity supported by generally accepted medical evidence.Consults with initial clinical reviewers as needed.In cases of non-certification determinations, conducts peer clinical reviews with attending physicians or orders providers within one business day of a request while in compliance with accreditation standards.When the clinical peer reviewer making the initial determination is not available, does peer to peer in his/her place.If peer to peer conversation does not result in certification, notifies provider of consumer’s right to initial and appeal and the related procedure.Performs medical or administrative appeals as needed based on medical policy, benefit language or standard of care.Additional Accountabilities and Essential FunctionsThe Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.Perform other job-related duties as assigned, within your scope of responsibilities.Job duties are performed in a normal and clean office environment with normal noise levels.Work is predominately done while standing or sitting.The ability to comprehend, document, calculate, visualize, and analyze are required.An Equal Opportunity EmployerIf you are an individual with a disability and require a reasonable accommodation to complete an application, please contact for assistance.
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