Medical Consultant for Post-Acute Care

2 weeks ago

Detroit, Michigan, United States Blue Cross Blue Shield of Michigan Full time

POSITION OVERVIEW


As the Medical Director for Post-Acute Care Utilization Management, you will be responsible for overseeing clinical evaluations related to Utilization Management for Post-Acute Care (PAC) admissions and guiding appropriate transitions to home care.

Engage in Peer-to-Peer discussions with hospital physicians as necessary to influence PAC facility admissions, whether prior to or following denials. The Medical Director will also offer clinical insights across the organization for various operational functions. This role includes interpreting, recommending, and reviewing corporate and medical policies within designated areas of expertise. Collaborate in the formulation and enhancement of clinical programs.

KEY RESPONSIBILITIES include, but are not limited to:


Providing clinical guidance and engaging in PAC utilization management, quality management, and care management initiatives, while identifying areas for improvement and efficiency.


Contributing to the design, development, implementation, and evaluation of disease management and health enhancement initiatives that promote the effective use of clinical resources in delivering high-quality post-acute medical care.

Leading clinical initiatives for health promotion and education programs, as well as overseeing the claims editing department.


Assisting in the establishment of corporate and regional programs aimed at improving care quality, minimizing medical expenses, and achieving favorable health outcomes.

Acting as a clinical resource and subject matter expert for both clinical and non-clinical personnel.

Conducting clinical reviews and facilitating peer discussions.


Engaging with physicians within the network regarding PAC medical policies, PAC utilization management, PAC claims editing, resource utilization, and quality standards.

Reviewing high-value claims and complex cases.

Participating in inter-rater reliability activities.

Contributing to committees and workgroups to meet departmental and corporate goals.

EDUCATIONAL BACKGROUND AND EXPERIENCE
A Doctorate from an accredited medical institution (M.D. or D.O.) is required.

Specialization in Physical Medicine and Rehabilitation (PM&R) is preferred.

A minimum of seven (7) years of clinical practice experience is necessary.


Previous experience as a medical director for a health plan, medical group, or hospital in utilization management or medical management for at least two (2) years is preferred.

CERTIFICATIONS AND LICENSES
  • Current, unrestricted Michigan state license as a Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).
  • Board certification or eligibility with ongoing efforts towards certification in a specialty recognized by the American Board of Medical Specialists or the American Board of Osteopathy.
  • Preferred certification in Utilization Review and Health Care Quality & Management.

QUALIFICATIONS
To excel in this role, candidates must effectively perform each essential duty. The qualifications listed below represent the necessary knowledge, skills, and abilities required. Reasonable accommodations may be made for individuals with disabilities to fulfill essential functions.

ADDITIONAL SKILLS AND ABILITIES
Over five years of post-residency patient care experience, ideally in inpatient or post-acute settings.

Strong communication skills, both written and verbal, for effective interaction with external physicians and organizations.

Demonstrated leadership capabilities, problem-solving skills, and the ability to manage multiple priorities.


Results-driven with a commitment to ownership of initiatives and collaboration with cross-functional teams to achieve departmental and corporate objectives.

Proficient in computer applications, particularly Microsoft Office Suite and web-based platforms.

Understanding of health plan operations related to utilization, care, and quality management, as well as familiarity with HEDIS/STARs and NCQA standards. Knowledge of CMS regulations and standards is beneficial.

Basic understanding of evidence-based clinical decision support guidelines (InterQual) and CPT coding principles.

Other relevant skills and abilities may be necessary to fulfill this role.


All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status, or status as an individual with a disability.

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