Medical Director – Care Management
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Job Description
Medical Director overseeing utilization management reviews for Florida Blue. Collaborating with teams and ensuring compliance with medical necessity standards.
Responsibilities:
- Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
- Discuss cases with physician providers (Peer to Peer)
- Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
- Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
- Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
- Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
- As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
- Participate in the development and review of Medical and Pharmacy policies as assigned
- Support the organization as a subject matter expert
- Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
- Perform other duties as assigned and needed by the organization
Requirements:
- Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Board Certification or Board eligibility by American Board of Medical Specialties or equivalent
- 5+ years of clinical experience
- Experience working in a dynamic, fast-paced environment
- Experience working both independently and in a team environment
- Exceptional verbal and written communication
- Physician reviewer or utilization management experience (Preferred)
- Primary Care Specialty physician experience (Preferred)
Benefits:
- Medical, dental, vision, life and global travel health insurance;
- Income protection benefits: life insurance, short- and long-term disability programs;
- Leave programs to support personal circumstances;
- Retirement Savings Plan including employer match;
- Paid time off, volunteer time off, 10 holidays and 2 well-being days;
- Additional voluntary benefits available;
- A comprehensive wellness program
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