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Resp & Qualifications

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 will be the management of care delivery in a cost effective and quality assured system that will assist the organization to achieve its corporate mission of serving the health needs of members.

ESSENTIAL FUNCTIONS:

+ Ensure that the provision of health care service to the membership is compliant with the medical policies and standards. Participate in medical necessity reviews, including pre-service reviews, concurrent reviews of inpatient and post-acute care, and appeals. Serves as key resource for network physicians for peer-to-peer case discussion.

+ Provides clinical support for utilization review, care management and quality to determine the medical effectiveness of proposed treatments and approve care management plans.

+ Provides clinical support for nursing staff, pharmacy, special investigations, legal, and public policy.

+ Participates in key committees, including credentialling, quality improvement, technology assessment, medical policy, care management and others, as assigned, ensuring that the company meets all regulatory and accreditation standards.

SUPERVISORY RESPONSIBILITY:

This position has no direct reports, however, may informally lead teams in a matrix environment.

QUALIFICATIONS:

**Education Level:** Medical Degree in Medical Degree from an accredited medical school, completion of an American residency program required with postgraduate training.

Licenses/Certifications Upon Hire Required:

+ MD - Physician - State Licensure Current license to practice in Maryland and DC without restriction.

+ Board Certification.

**Experience:** 8 years clinical practice experience.

Preferred Qualifications:

+ Experience in utilization management or served as physician advisor for utilization review in healthcare entities. Previous experience working for healthcare payor organization.

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., Advanced

+ Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

**Salary Range:** $223,680 - $415,206

Salary Range Disclaimer

The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).

Department

Medical Directors

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide 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 him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate 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

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REQNUMBER: 21521