Provide clinical expertise across the enterprise for various functions. Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility. Advise and collaborate in the development of clinical programs. Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency. Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care. Provide clinical leadership for health promotion and education programs and the claims editing department. Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes. Serves as clinical resource and subject matter expert to both clinical and non-clinical staff. Perform clinical reviews and conduct peer to peers. Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality. Perform high dollar claims and complex case reviews. Participate in inter-rater reliability activities. Participate in committees and workgroups to achieve department and corporate objectives. "Qualifications" Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required. Seven (7) years clinical practice experience. Two (2) years of previous medical director experience working for a health plan, medical group, or hospital in utilization management or medical management preferred. Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license. Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy. Certification in Utilization Review and Health Care Quality & Management is preferred. Ability to effectively communicate with external physicians and organizations. Proven leadership, problem solving, and the ability to manage multiple priorities. Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals. Demonstrated skill with Microsoft Office Suite and web-based programs. Understanding of health plan functions related to utilization, care, and quality management as well as HEDIS/STARs and NCQA. Familiarity with CMS regulations and standards. Basic knowledge of evidence-based clinical decision support guidelines (InterQual). Basic knowledge of CPT coding and guidelines. Other related skills and/or abilities may be required to perform this job. All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
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