Medical Director

Medical Director (Hybrid) – CareFirst BlueCross BlueShield Purpose The Medical Director oversees all activities of utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans. The critical responsibility is to manage care delivery in a cost‑effective and quality‑assured system that assists the organization in achieving its mission of serving the health needs of members. Essential Functions Ensure that the provision of health care services to the membership is compliant with medical policies and standards. Participate in medical necessity reviews, including pre‑service reviews, concurrent reviews of inpatient and post‑acute care, and appeals. Serve as a key resource for network physicians for peer‑to‑peer case discussion. Provide clinical support for utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans. Provide clinical support for nursing staff, pharmacy, special investigations, legal, and public policy. Participate in key committees, including credentialing, quality improvement, technology assessment, medical policy, care management, and others as assigned, ensuring the company meets all regulatory and accreditation standards. Supervisory Responsibility This position has no direct reports but may informally lead teams in a matrix environment. Qualifications Education: Medical Degree from an accredited medical school with completion of an American residency program and postgraduate training. Licenses/Certifications: MD – Physician license to practice in Maryland and DC without restriction; Board Certification. Experience: 8 years clinical practice experience. Preferred Qualifications: Experience in utilization management or service as physician advisor for utilization review in healthcare entities, preferably with a payor organization background. Knowledge, Skills, and Abilities (KSAs): Knowledge of managed care concepts and care management activities. Skilled in coordinating and collaborating with physicians. Knowledge of patient rights and laws relative to those rights, such as HIPAA. Demonstrated application and knowledge of best health clinical practices. Knowledge of principles, practices, evidence‑based guidelines, and standardized processes and procedures for evaluating medical support operations business practices. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, delivering service excellence and effective communication even with demanding or challenging customers. Salary Range $223,680 - $415,206 Salary Range Disclaimer The disclosed range estimate has not been adjusted for the applicable geographic differential. It is based on the scope and responsibilities of the position, the candidate’s experience, education/training, internal peer equity, and market considerations. Compensation decisions depend on each case’s facts and circumstances. Department Medical Directors Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. The company provides equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information. Where To Apply Please visit our website to apply: www.carefirst.com/careers Federal Disc/Physical Demand Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Physical Demands The position is primarily seated, with occasional walking or standing required. Hands are regularly used to write, type, key, handle, or feel small controls and objects. The incumbent must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. Sponsorship in US Must be eligible to work in the U.S. without sponsorship. #J-18808-Ljbffr