- Primary responsibility will be to perform utilization reviews according to federal and state guidelines and internal medical policies.
- Consult with internal medical directors as needed to discuss UM and medical policies for specific diagnoses and conditions emphasizing evidence-based medicine.
- Become an effective member of the medical management team, which is responsible for improving the health of plan members and ensuring the provision of medically necessary services.
- Communicate optimally across multiple functional areas at BCBSMN to promote awareness, alignment and collaboration and ensure organizational objectives are achieved.
- Provide education for internal staff and providers on the needs of populations being served, as needed.
- Promote active consultation to avert complications of acute and chronic illness.
- Provide clinical input to accreditation team and regulatory compliance.
- Quality of care reviews and participation in QOC committee
- Seek to continually improve member satisfaction and health outcomes.
- Serve as an ambassador to the community for improving care, as needed.
- Support efforts to foster a collaborative relationship with network providers, including medical groups and individual providers and associated community leaders.
- Enhance team collaboration and assist in conflict resolution.
- Provide clinical input to Data/Analytics team in development and implementation of new analytical/reporting tools, when requested.
- Participate with BCBSMN team members in developing forums and other venues to provide opportunities for education.
- 7+ years of related professional experience, with 3+ years of health plan payer experience. All relevant experience including work, education, transferable skills, and military experience will be considered.
- Accepting this director level position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.
- Able to learn and work in new UM platforms
- Board certification in Psychiatry and several years of clinical and administrative experience are required.
- Unencumbered license to practice medicine in Minnesota (or initiation of application required for start date)
- Ability to establish trust and credibility at all levels of the BCBSMN organization.
- Proficient in leading discussions and public speaking with large and small groups.
- Data driven, process and outcome oriented, and customer focused.
- Professional, approachable, and engaging communication/work style that engenders trust, credibility, and collegiality.
- Proven history of applying data driven reports resulting in actionable solutions.
- Ability to understand metrics at granular levels and in-depth experience with data, health care economics and reporting.
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Medical Director - Saint Paul, MN, United States - Blue Cross and Blue Shield of Minnesota
Description
About Blue Cross Blue Cross and Blue Shield of Minnesota is one of the most recognized and trusted health care brands in the world with 2.5 million members. We're committed to reinventing health care to improve health for our members and the community. We hope you'll join us. How Is This Role Important to Our Work? The Medical Director will work in Medical Management to provide primarily utilization management and case management review for mental health . In addition, applicant shall provide clinical oversight of staff and serve as a liaison among internal departments, as needed. A Day in the Life:Teleworker Role designation definition: Teleworking is working full time remote. Hybrid is a combination of working onsite and remotely. Onsite is full-time onsite. Make a difference Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, gender expression, or any other legally protected characteristic. Reasonable Accommodation for Job Seekers with a Disability: If you require reasonable accommodation in completing this application, interviewing, completing any pre-employment testing, or otherwise participating in the employee selection process, please direct your inquiries to All roles require a high school diploma (or equivalency) and legal authorization to work in the U.S. Blue Cross and Blue Shield of Minnesota and Blue Plus are nonprofit independent licensees of the Blue Cross and Blue Shield Association.
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