Medical Director – Medicare Advantage
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Job Description
Medical Director at BlueCross BlueShield of Louisiana overseeing treatment procedures and ensuring compliance with guidelines. Supporting utilization management and healthcare operations in Louisiana.
Responsibilities:
- Promote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement.
- Reviews treatment procedures and services to ensure that they are within established guidelines or supported by generally accepted medical evidence when formal guidelines do not exist.
- To provide direction to operations as applicable, including utilization activities.
- Facilitates all physician and provider committees as needed.
- Provides advice on external contractual benefit issues.
- Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims related issues.
- Participates in and supports internal operations such as quality assurance efforts, the BCBSLA Quality Improvement Plan, accreditation/URAC related activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives.
Requirements:
- Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) required
- 7 years of clinical practice experience is required
- 3 years of post graduate experience with direct patient care required; prefer 5 years of experience
- Administrative experience in a health plan and/or a working knowledge of the insurance industry preferred
- Prior detailed experience in either utilization, case or disease management in a hospital or health plan setting preferred
- Experience with external accreditation bodies; JCAHO, URAC, or NCQA preferred
- Medicare Advantage experience is preferred
- Current, license to practice medicine in Louisiana of the type and scope that permits application of clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination
- Must have the ability to obtain a medical licensure for the state of Louisiana required
- Board certification in a specialty recognized by ABMS required.
- Excellent communication, presentation, interpersonal and human relation skills are required.
- Microsoft Office software Word, Excel, Outlook, PowerPoint proficiency required.
Benefits:
- We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities.
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