Medical Director

3 days ago

Omaha, United States BlueCross BlueShield of Nebraska Full time

Blue Cross and Blue Shield of Nebraska (BCBSNE) is more than just an insurance company; we exist to be there for people in the best and hardest moments of their lives.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community. BCBSNE is happy to offer four work designations for our Omaha area employees: 100% in-office, Hybrid - 3 days in office, Hybrid - 2 days in office, 100% remote. Occasional visits to the office.

This position is a physician leader who provides leadership in utilization, prior authorization and case management for BlueCross BlueShield of Nebraska. The individual is responsible for enhancing relationships with providers and facilities, make utilization and prior authorization determinations, assist in case management and be a project manager for medical management programs. This position will act as a back-up to the Chief Medical Officer.

What you'll do: Assist the Chief Medical Officer with medical policy related business decisions.

Acts as an administrative and clinical leader to other Medical Directors

Oversee utilization review/quality assurance, directing case management

Support the Medical Management staff ensuring timely and consistent responses to members and providers.

Act as lead business and clinical liaison to network providers and facilities to support the effective execution of medical services programs by the clinical teams

Provide clinical expertise and business direction in support of medical management programs through participation in clinical team activities

Responsible for predetermination reviews ad reviews of claim determinations, providing clinical, coding, and reimbursement expertise

Craft and implement interventions that improve outcomes

Provide alternative approaches that can improve practice performance while achieving similar or greater clinical quality

Conduct peer to peer conversations with the attending physician or ordering providers.

To be considered for this position, you must have: PHD in Medicine (M.D or D.O) and ten (10) years of experience in Health Care Delivery System e.g., Clinical Practice and Health Care Industry.

Board Certified in an American Board of Medical Specialties Board, and an active, unrestricted license to practice medicine in a state or territory of the United States, including post graduate direct patient care experience required.

Nebraska active, unrestricted clinical license.

Three (3) years of direct clinical care in private and/or academic practice.

Three (3) years prior experience with Medicare Advantage.

Three (3) years prior managed care experience.

Previous experience with administrative oversight of the medical function of an insurance (or related) company.

An equivalent combination of education and experience may be substituted for this requirement. The ability to meet or exceed the attendance and timeliness requirements of their departments. The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned. The strongest candidates for this position will also possess: A Master's Degree in Business Administration (MBA)

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers. We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members. Blue Cross and Blue Shield of Nebraska is an Equal Opportunity /Affirmative Action Employer -

Minorities/Females/Disabled/Veterans

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