Future Opportunites- Medical Director

Company: Excellus Blue Cross Blue Shield
Location: Rochester
Posted on: September 17, 2020

Job Description:

Summary

The Medical Director participates in the broad array of activities of the Medical Services area including Medical and Pharmacy Utilization Management, quality management, case management, credentialing, and corporate medical policy processes. The incumbent also provides input into the development of policies, programs and strategic objectives that cover Medical Management Services, and acts as a liaison with local physicians and hospitals, and keeps abreast of medical policies and procedures within the medical community.

Essential Responsibilities/Accountabilities

• Assists the Medical Services Department with Utilization Review and Case Management activities. These activities do not, in any way, constitute practicing medicine.

• Reviews and makes recommendations and/or decisions on Utilization or Case Management activities; utilization review activities include reviews of requests for broad range of medical services including medications, medical and surgical services at first level, appeal and inquiries.

• Makes accurate and consistent interpretation of integral medical policy, contract benefits and State and Federal Mandates and maintains current and working knowledge of Utilization Management Standards.

• Clinical skills are excellent and evidence based medicine skills are such that the individual provides review oversight for a broad array of clinical services.

• Reviews and makes recommendations on medical policies, guidelines and medical criteria.

• Provides input into the utilization management program policies and procedures.

• Assists with training medical director colleagues, nursing staff including leadership of teaching grand round activities.

• Assists the staff during high peak activity or staff outages.

• Act as a resource to legal counsel; and provides testimony in legal proceedings as required.

• Maintains professional contacts with local Physician community and keeps abreast of medical and managed care trends.

• Attends medical policy, medical director meetings and staff grand rounds meetings

• Take week-end call, as assigned.

• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.

• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.

• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.

• Regular and reliable attendance is expected and required.

• Performs other functions as assigned by management.

Note:

• The position is considered an exempt employee status with an expectation to work those hours which are required to accomplish the work deliverables including occasional evenings during high volume periods and staff shortages (e.g. cross coverage vacations).

• Work from home is an option with an expectation of full compliance with the corporate ‘Work from Home’ policy

Level II – Performs similar functions as level I, plus:

• Reviews medical literature and applies evidence based principles using high proficiency skills for a broad range of clinical services.

• Reviews internal trend reports to assess present and future needs and opportunities.

• Interacts with regulatory and accreditation agencies as assigned.

• Provides clinical support to the Sales and Marketing divisions

• Provides clinical leadership for the implementation of new utilization/case/quality management initiatives

Minimum Qualifications

NOTE:

We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

Level I

• Medical Degree (MD) required.

• Active unrestricted medical license; appropriate and current board certification.

• A minimum of ten years medical experience and strong working knowledge of QM/UM and credentialing activities or (5) years of comparable health plan experience.

• Ability to identify, analyze and resolve complex medical issues.

• Skills in evidence based medicine.

• Strong interpersonal skills essential for communication to staff at all levels of the organization.

• Basic skill sets in electronic communication systems such as e-mail and Word.

Level II – requires similar qualifications as level I, plus:

• Superior evidence based medicine skill set

• Strong interpersonal skills essential for communication to physicians in the community.

• Strong verbal presentation skills to lead internal and external discussions at board levels

• Advanced skill sets in electronic communication systems such as e-mail, Word, PowerPoint, and Excel.

The Physician is not the subject of any pending professional disciplinary action impairing his/her ability to practice medicine.

Physical Requirements

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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Qualifications Education Required

Physician or better in Physician.

Licenses & Certifications Required

Medical Doctor

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: Excellus Blue Cross Blue Shield, Rochester , Future Opportunites- Medical Director, Other , Rochester, New York