- Complex Care/Case Management Review
- Support clinical nursing team in daily operations
- Perform peer to peer communication with facility providers
- Lead case management clinical rounds
- High-cost claimant data gathering and analysis
- Forward facing meetings for High-cost claimant reviews
- Clinical strategy meetings
- Present semi-annual and annual reviews on plan performance
-
Medical Director
1 week ago
Centene Corporation Columbia, United StatesYou could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.* ...
-
Senior Center Medical Director
1 week ago
ChenMed Columbia, United States**We're unique. You should be, too.**We're changing lives every day. For both our patients and our team members. Are you innovative and entrepreneurial minded? Is your work ethic and ambition off the charts? Do you inspire others with your kindness and joy?We're different than mo ...
-
Medical Director Role in Columbia SC
1 week ago
The Curare Group Columbia, United StatesA Cancer Center situated in central South Carolina is actively seeking a proficient Hematologist/Oncologist with significant clinical leadership experience to assume the role of Practice Medical Director. This presents a remarkable prospect for a forward-thinking and clinically a ...
-
Associate Medical Director, Client Support
1 week ago
BlueCross BlueShield of South Carolina Columbia, United StatesSummary · Provides direct physician support. Oversees health and disease management programs. Oversees utilization management case evaluation for medical necessity. Reviews and communicates medical decisions. Interacts with network physician providers to resolve case-by-case comp ...
-
Hayman Daugherty Associates, Inc Columbia, United StatesJob Overview · A large metro hospital is seeking a GI medical director with 5-10 years of experience and academic ties. · A GI fellowship program is in the planning stages and the system is looking to expand the department once a director is found. Prior leadership experience is ...
-
Nurse Practitioner
6 days ago
NHC Columbia, United StatesPosition: PRN Nurse Practitioner · Pay: $100 Per Visit · The Nurse Practitioner serves as a member of the Hospice Interdisciplinary Team and has responsibility for the medical component of the Hospice Patient Care Program. Collaborates with Medical Director and Attending Physic ...
-
Certified MC Med Tech
1 week ago
Watercrest Senior Living Columbia, United States Full timeSERVANT LEADERSHIP: · Watercrest Senior Living Group associates answer a calling to serve seniors and their families every day. They are recognized for their achievements and empowered to share their vast experience with their peers ensuring the quality of our assisted living an ...
-
Hayman Daugherty Associates, Inc Columbia, United StatesJob Overview · Pulmonology/Critical Care Physician Job Near Columbia, SC · An excellent opportunity for a fellowship trained Pulmonology/Critical Care; Pulmonologist; or Pulmonology/Sleep physician to join a hospital-based group. It is open to Pulmonologists with or without Criti ...
-
Executive Assistant I
1 week ago
State of South Carolina Columbia, United StatesJob Responsibilities · Executive Assistant · The South Carolina Department of Administration is seeking a Senior Executive Assistant who will provide timely and professional support to the agency's Executive Director, Chief of Staff and to the Office of Executive Director. · In t ...
-
Hayman Daugherty Associates, Inc Columbia, United StatesJob Overview · Gastroenterology Physician Job near Columbia, SC · Seeking a BC/BE Gastroenterologist to join an established hospital affiliated practice located near Columbia, South Carolina. The established provider is retiring and we are seeking a physician who would like to en ...
-
General Surgeon Needed in Columbia, SC
1 week ago
Hayman Daugherty Associates Columbia, United StatesJob Overview · General Surgeon Needed in Columbia, SC · Join an experienced group of General Surgeons in a Hospital-Employed setting. With a forward-thinking and dynamic pulse, there are a multitude of reasons why Columbia, SC is known as the Real Southern Hot Spot. The area's po ...
-
DADE/ ID Medical Consultant
1 week ago
State of South Carolina Columbia, United StatesJob Responsibilities · Careers at DHEC: Work that makes a difference · Embracing Service, Inspiring Innovation, Promoting Teamwork, Pursuing Excellence, and Advancing Equity · This position is located in the Division of Acute Disease Epidemiology/Immunizations within the Bureau o ...
-
Operations Management Program Director
4 days ago
Sevita Columbia, SC, United StatesExplore Numerous Nearby Locations for Your Convenience · Schedule an Interview First - Apply Afterwards · DISCOVER CAREERS, WELL LIVED. Our mission at Sevita is to create a world where every person has the right to live well. As a Caregiver, you'll provide assistance and strategi ...
-
physician whole health clinical dir
1 week ago
Department of Veterans Affairs Columbia, SC, United StatesSummary · As Clinical Director for the Whole Health Program, you will manage and plan how services are delivered and contribute to the process of strategic planning, influencing and responding to organizational priorities. Included responsibility; creating an annual Whole Health ...
-
Memory Care Manager
1 week ago
NHC Columbia, United StatesThe Palmettos of Parklane - Memory Care Manager · This is a full-time position and reports to the Director of Health Services and Executive Director · The Program Director plans, organizes, develops and leads the overall operation in the memory care unit in accordance with fede ...
-
Prisma Health Columbia, United StatesInspire health. Serve with compassion. Be the difference. · Job Summary · The Prisma Health Physician is responsible for the provision of quality medical services to patients of Prisma Health-University Medical Group · Accountabilities Depending on setting and specialty, provi ...
-
Staff Development Nurse
6 days ago
Lutheran Homes of South Carolina Columbia, United StatesJob Description · The incumbent is responsible for assisting the Director of Nursing in planning, organizing, developing, and directing the day-to-day functions of the Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and reg ...
-
Clinical Testing Neuropsychologist
1 week ago
LifeStance Health Columbia, United StatesWe are looking to hire talented Licensed Neuropsychologists in the area, who are passionate about patient care and committed to clinical excellence. · Our practice is currently a combination of therapists, psychiatrists, nurse practitioners, and psychologists with backgrounds in ...
-
Call Center Specialist
2 days ago
US Tech Solutions, Inc. Columbia, United StatesJob Title: Call Center Specialist · Work Location: Columbia SC 29203 · Duration: 3+ Months (Possible Contract to Hire) · Job Description: · Monday-Friday, 8:30am-5pm mandatory ot on occasion. contract to hire onsite position, with potential to work remotely must be a local ca ...
-
Clinical Testing Neuropsychologist
2 days ago
LifeStance Health Columbia, United StatesAt LifeStance Health, we believe in a truly healthy society where mental and physical healthcare are unified to make lives better. Our mission is to help people lead healthier, more fulfilling lives by improving access to trusted, affordable, and personalized mental healthcare. E ...
Associate Medical Director - Columbia, United States - BlueCross BlueShield of South Carolina
Description
SummaryProvides direct physician support. Oversees health and disease management programs. Oversees utilization management case evaluation for medical necessity. Reviews and communicates medical decisions. Interacts with network physician providers to resolve case-by-case complaints. Oversees medical aspects of vendor relationships. Assists in developing medical policy.
Description
Provides medical and administrative oversight of the health and disease management programs including budgeting, program strategic planning, and review of outgoing correspondence and printed materials. Provides presentations on health and disease management as assigned.
Provides direct physician support. Assists in compliance with regulatory bodies. Performs utilization management review functions including pre-admission review, continues stay review, procedure precertification, post-service reviews, emergency room visit reviews, and individual case management needs.
Serves as medical resource for quality improvement and National Committee for Quality Assurance (NCQA) and Health Plan Employer Data and Information Set (HEDIS) initiatives. Functions as liaison to medical community.
Acts as resource for providers/internal staff on medical policies. Educates providers on issues concerning medical policies, utilization specifications, coding/medical necessity issues. Conducts research into new/controversial medical procedures/technology as assigned to propose possible policy, coverage criteria, utilization specifications and coding recommendations.
Participates in medical review policy/quality programs and inter-reviewer reliability studies. Maintains familiarity with applicable regulations (state, federal) as well as any oversight agency/entity rules such as National Committee for Quality Assurance (NCQA), Department of Insurance (DOI), or URAC.
Additional:
Required Work Experience: 8 years broad clinical experience to include knowledge of utilization and medical review. Experience may include paid training.
Required Skills and Abilities: Demonstrated ability to direct multiple strategic projects. Excellent verbal and written communication skills. Excellent judgment, organizational, customer service, presentation skills. Excellent analytical or critical thinking skills. Knowledge of strategic concepts. Ability to persuade, negotiate, or influence others. Working knowledge of word processing, spreadsheet, and presentation software.
Required Software and Tools: Microsoft Office.
Required Licenses and Certificates: Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.
Preferred Education: Bachelor's degree- Business Administration or Public Health
Preferred Work Experience: 2 years-medical data analysis/analytical capability to interpret statistical information.
Preferred Experience: Inpatient or previous Healthcare Case Management oversight experience preferred Care Management Physician Certification or Other formal Case Management training preferred.
Preferred Skills and Abilities: Experience with medical oversight of quality improvement activities. Experience with quality committees or NCQA. Experience with population based disease management or public health initiatives. Experience in medical management or managed care. Demonstrated understanding of Medicare programs.
Work Environment: Typical office environment. Extended periods of sitting, working at personal computer. Some walking, standing, moving of boxes.
This role is hybrid, with 3 days in office onsite at our Percival Road location. 20 to 25% travel expected.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.
Some states have required notifications. Here's more information.
Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
We are committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities.
If you need special assistance or an accommodation while seeking employment, please e-mail or call , ext with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.
