Provides medical guidance and support to the full spectrum of Capital’s Clinical Management activities and programs. Chairs or participates in Capital’s Clinical Management Committees at the discretion of the Managing Medical Director.
Participates in strategic planning and other corporate projects for Capital at the discretion of Senior Management. Represents Capital in the medical provider community.
This is an independently contracted position to accommodate both schedule flexibility and the needs of the business.
Essential Duties and Responsibilities
Supports the department with regard to the development, review, and periodic updating of Capital’s medical necessity policies.
Helps to promote Capital’s clinical vision and programs in the local medical community and within Capital’s 21-county service area.
Serves as chair or participating member of Corporate Clinical Management Committees at the direction of the Managing Medical Director.
Collaborates with, provides advice to, and directly supports the Vice President of Medical Management and other Clinical Management Staff on all clinical aspects of Capital’s clinical management programs, including Capital’s Quality Management, Prior-Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs.
Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director.
Supports organizational accreditation efforts and regulatory review processes.
Reviews and analyzes utilization data and provides support to Capital’s Medical Informatics and Actuarial areas.
Provides business requirements for information systems that support medical director functions.
Provides medical support to, and otherwise participates in, high-level corporate leadership teams, including the Cross Functional Senior Leadership Team and corporate special project teams as requested.
Provides or arranges for medical input and / or research regarding best practices in the areas of medical policy development, utilization management, quality management, benefit administration, claims administration and provider contracting.
Collaborates with local area medical leaders as requested by the Managing Medical Director.
Participates in the development of new or modified benefits for inclusion in Capital’s certificates of coverage. Effectively collaborates with Capital’s Marketing, Rating and Underwriting, Legal, Customer Service, Provider Affairs, Benefits Management, and Audit departments.
Assists with the development of Capital’s provider networks and partnerships at the direction of the Managing Medical Director.
Maintains a network of physician peer-review specialists to assist Capital in making medical necessity determinations, benefit determinations, quality of care determinations, and appeals and grievances decisions involving medical decision making.
Serves as Capital’s medical liaison with affiliated and / or subsidiary organizations.
Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation.
Directs and reviews medical necessity determinations made by contracted consulting physicians and other external reviewing entities.
Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
Performs other related duties and assignments as directed.
Knowledge of current and emerging medical treatment modalities.
Familiarity with National Committee for Quality Assurance (NCQA) / URAC standards.
Demonstrated public speaking and written communication skills.
A minimum of five years clinical experience, post residency, including both inpatient and outpatient care.
At least three years’ experience in managed care, utilization review, and / or quality management.
Minimum of three years’ experience in a management or leadership position in the health care industry.
PC literacy and ability to perform electronic research and respond to electronic requests.
Education, Certification, and Licenses :
Minimum requirements include an MD or DO Degree, as well as appropriate Board Certification.
Current unrestricted licensure in Pennsylvania as an MD or DO.
Currently covered by, or eligible to be covered by, medical liability insurance.
Current valid Pennsylvania drivers’ license to travel to and from provider / member / customer locations.
Work Environment :
Physical Demands : While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see.
The employee must be able to work over 40 hours per week. The employee must occasionally lift and / or move up to 5 pounds.
Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity / affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.