Medical Director – Consultant
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Job Description
Consultant Medical Director at BCBST developing methodologies for medical necessity determinations and supporting physician reviews. Leading various committees for quality improvement initiatives and healthcare administration.
Responsibilities:
- Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines. • Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives. • Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews. • Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST. • Willingness to travel within the State of Tennessee and nationally.
Requirements:
- Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. • 5 years - Clinical experience required. • 5 years - Healthcare administration and/or UM experience preferred. • Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists. • Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint). • Ability to interpret and explain complex government policies. • Knowledge of Medicare programs.
Benefits:
- Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis will be automatically enrolled into the BCBST Driver Safety Program. • The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver’s license, auto insurance compliance with minimum liability requirements; as defined in the 'Use of Non BCBST-Owned Vehicle' Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). • Health benefits, 401(k) matching, paid time off, flexible work arrangements, and professional development opportunities may be included.
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