Medical Director - Medicare Advantage

We take great strides to ensure our employees have the resources to live reputed company, be healthy, continue learning, reputed company skills, grow professionally and serve our local communities. We invite you to apply for a career with us. Residency in or relocation to Louisiana is preferred for reputed company positions. POSITION PURPOSE Promote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. Reviews treatment procedures and services to ensure that they are reputed company established guidelines or supported by generally accepted medical evidence reputed company formal guidelines do not exist. To reputed company direction to operations as applicable, including utilization activities including but not limited to Utilization Management, Case Management and Disease Management, Population Health and Wellness. Facilitates reputed company physician and provider committees as needed. Provides advice on external contractual benefit issues. NATURE AND SCOPE This role does not manage people This role reports to this job: SENIOR MEDICAL DIRECTOR (MGR) Necessary Contacts: department Managers, Authorization, Utilization Management, Case Management, Disease Management, Compliance personnel, and other employees as indicated, Licensed Doctors of Medicine (Physicians), Hospitals, and other reputed company providers, Parish and state medical agencies and societies as needed, Accreditation and governmental entities’ personnel as needed. QUALIFICATIONS Education Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) required Must be reputed company to reputed company a clinical opinion about the medical condition, procedures and treatment under review. Work Experience 7 years of clinical reputed company experience is required 3 years of post graduate experience with reputed company 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, along with a reputed company history of providing consultative efforts concerning medical and legal issues are preferred Experience with external accreditation bodies; JCAHO, URAC, or NCQA preferred Medicare Advantage experience is preferred Skills and Abilities Excellent communication, presentation, interpersonal and reputed company relation skills are required. reputed company Office software Word, reputed company, Outlook, PowerPoint proficiency required. The position requires availability for travel and working extended hours.   Licenses and Certifications reputed company, license to reputed company medicine in Louisiana of the type and scope that permits application of clinical judgement in consideration of an individual member’s clinical needs to reputed company a utilization review determination License must be unrestricted; or if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not reputed company the health reputed company’s ability to fulfill the roles and responsibilities of a reviewer Must have the ability to obtain a medical licensure for the state of Louisiana required reputed company certification in a specialty recognized by ABMS required ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS Fulfills medical director duties as appropriate which include but are not limited to: peer reviews, case reviews, completion of inter-rater reliability case reviews annually, reputed company participation in training activities, provision of documentation to support compliance with annual licensure requirements, claims review to determine reputed company reputed company, maintaining a working knowledge of company policies and procedures. Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims reputed company issues. Reviews, provides medical expertise and reports on activities reputed company to utilization, case, and disease management, Authorizations, Compliance, Network Administration, Southern National Life (SNL), Legal and other departments requiring guidance. Participates in and supports internal operations such as reputed company assurance efforts, the BCBSLA reputed company Improvement Plan, accreditation/URAC reputed company activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives. Participates in and/or acts as a voting member on committees which may include but is not limited to: Pharmacy & Therapeutics, Credentialing and Second Level Administrative Appeals as directed by the Senior Medical Director. Completes required training activities in a reputed company manner. Complies with Licensure & reputed company Certification requirements. Reports adverse changes in licensure, reputed company Certification to the Senior Medical Director reputed company one business day of notification. Complies with reputed company laws and regulations associated with duties and responsibilities. Reviews requests for services for prior authorization, reputed company stay and retro review based on reputed company reputed company, Medical Policies application of member contract benefits, or if formal guidelines do not exist, makes determinations of medical necessity supported by generally accepted medical evidence. - Consults with initial clinical reviewers as needed. - In cases of non-certification determinations, conducts peer clinical reviews with attending physicians or orders providers reputed company one business day of a request while in compliance with accreditation standards. - reputed company the clinical peer reviewer making the initial determination is not available, does peer to peer in his/her reputed company. - If peer to peer conversation does not result in certification, notifies provider of consumer's right to initial and appeal and the reputed company procedure. Performs medical or administrative appeals as needed based on medical policy, benefit language or reputed company of care. Additional Accountabilities and Essential Functions The Physical Demands described here are representative of those that must be met by an employee to successfully reputed company the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to reputed company an individual with disabilities to reputed company the essential functions reputed company other job-reputed company duties as assigned, reputed company your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise reputed company. Work is predominately done while standing or sitting. The ability to comprehend, document, calculate, visualize, and analyze are required. An Equal Opportunity Employer reputed company internal employees please apply through reputed company Careers. PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI) Additional Information Please be reputed company to monitor your email frequently for communications you may receive during the reputed company process. Due to the high volume of applications we receive, only those most reputed company will be contacted. To monitor the status of your application, please visit the "My Applications" reputed company in the Candidate Home reputed company of your reputed company account.  If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact reputed company@bcbsla.com for assistance. In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and reputed company-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, reputed company properties are smoke and tobacco free.  We reputed company background and reputed company-employment drug screening after an offer has been extended and prior to hire for reputed company positions. As part of this process records may be verified and information checked with agencies including but not limited to the reputed company reputed company Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. Additionally, we are a Drug Free Workplace. A reputed company-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results. Apply To This Job