Internal Reference Number: R1052400
Summary Why should you join the BlueCross BlueShield of South Carolina family of companies?
Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina ... and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!
Position Purpose:
The Behavioral Health Medical Director provides medical leadership to specific health plan or LOB to include overseeing physician review, utilization review/quality assurance, directing case management, developing and implementing medical policies and standards, evaluating new technologies and treatments. In this role, you will identify trends in medical management and proactively aid in setting direction to improve these.
The Behavior Health Medical Director that we seek will have extensive experience in the following areas:
STRATEGIC AND CLINICAL LEADERSHIP
The Medical Director provides clinical oversight for all behavioral health activities across utilization management, care coordination, quality, and population health for South Carolina Medicaid. The role ensures Healthy Blue's BH strategy aligns with SCDHHS priorities, providing clinical authority to direct program strategy, oversee clinical policies, and support statewide goals such as improved transitions of care and reduced emergency department dependence.
UTILIZATION AND COST MANAGEMENT
The Behavioral Health Medical Director ensures defensible, evidencebased utilization decisions; provides clinical review for complex and highcost cases; and partners with internal program integrity teams to identify inappropriate utilization patterns. This role directly impacts Healthy Blue's costofcare performance while maintaining member safety and compliance with SCDHHS expectations for medically necessary, leastrestrictive care.
MEMBER SAFETY, INTEGRATED CARE, AND HEALTH EQUITY
This position provides clinical leadership for integrated BH/medical models, supports suicide prevention and crisis response initiatives, and oversees transitions-of-care strategies to reduce readmissions and adverse events. The role advances health equity by promoting culturally responsive care and addressing disparities across South Carolina's rural and urban regions.Description
Location:This position is full-time (40-hours/week) Monday-Friday REMOTE in South Carolina. You will be required to come to on-site twice monthly.
Sponsorship: This position is not eligible for sponsorship now or in the future.
What You'll Do:
Provides leadership and medical support on medical and regulatory matters. Identifies trends in medical and pharmacy costs, utilization trends, and proactively makes recommendations and initiates solutions to impact these.
Provides leadership to clinical team and operations in order to increase compliance, improve efficiency, and increase communication. Acts as resource for providers, staff, part time medical reviewers, and as requested, customers, on issues concerning medical policies and regulations.
Provides clinical support to Payment Integrity Unit(s) to analyze abuse patterns and recommend solutions.
Provides oversight and leadership with quality improvement and health plan and medical program accreditation(s).
Works with staff and other leadership in developing ideas related to quality initiatives, good clinical support, and outreach to the network.
Responsible for physician review (UM, Appeals, CM) - reviews physician and provider practice pattern analysis and other statistical data.
Conducts research into new or controversial medical procedures and technology.
Educates staff, network providers, and medical community on various aspects of medical policy and program administration.
To Qualify for This Position, You'll Need the Following:
Required Education:Doctorate Degree - Medical Doctor (MD) with current active medical license, without restriction. If Behavioral Health, Medical Director - Doctor of Psychiatry with current active medical license, without restriction.
Required Work Experience:
8 years post graduate experience in direct patient care.
Required Skills and Abilities:
Managed care knowledge and experience required.
Working knowledge of regulatory and accreditation entities, i.e., URAC, NCQA, DOI, and DOL standards.
Excellent verbal and written communication skills.
Excellent customer service, organizational, and presentation skills.
Good judgment skills.
Proficiency in spelling, punctuation, and grammar.
Ability to persuade, negotiate, or influence others, represent our company well.
Ability to work as a team member as well as a leader.
Required License and Certificates: Active, unrestricted medical license from... For full info follow application link.
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
