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Medical Director, Medicare Advantage / ACA

Company: Blue Cross and Blue Shield of Kansas City
Location: Kansas City
Posted on: September 17, 2020

Job Description:

Medical Director, Medicare Advantage / ACA. Are you interested in learning about healthcare professions and the latest healthcare innovations in the KC area? Become part of an organization that is dedicated to making a difference in both your career and community.. Job Description Summary :. The Medical Director actively uses their clinical training, experience and judgement to make determinations whether requested services, requested level of care, and/or requested site of service should be authorized. The Medical Director will apply various clinical policies, state and federal guidance, and contracts in decision making. Will provide expertise from a clinical perspective for various organizational projects and inquiries and be a leader in providing clinical guidance in a variety of activities.. Job Description. · Provide computer-based clinical reviews of moderately complex to complex clinical scenarios to include a review of all submitted clinical records, external telephonic conversations with the providing physician in the form of Peer-to-Peers, and close collaboration with the nursing team.. · Serve as expert/resource on appeals related to utilization management issues.. · Possess excellent verbal communication skills as this position will speak with various leaders including external physicians, physician groups, hospitals, post-acute facilities, and community groups, value-based contracting relationships, disease / care management, and general population health in support of BlueKC priorities.. · Participate in or chair various committee meetings (e.g. Credentialing, Peer Review, or Medical and Pharmacy Management Committee).. · Able to review at overall data to then inform strategy around continuous improvement of healthcare delivery as well as individual decision making.. · Demonstrate critical thinking skills in decision making by applying the correct guidelines in the greater context of delivering the best quality of care to members while achieving cost efficiency.. · Display ability to have active listening skills, ask key questions, and demonstrate compassion towards all parties when making decisions that may not have universal agreement, particularly around utilization review activities.. · Review individual member experiences to identify where care gaps exist and identify resources (external and internal), participate in group rounds to discuss complex cases from a wholistic perspective, and assure that evidence- based guidelines are driving care decisions.. · Possess a broad base of medical knowledge but also a willingness to learn and expand clinical acumen to provide decision making across all medical specialties as well as having a collaborative approach to seek additional input where needed to arrive at the best decision.. · Provides clinical expertise for quality management area with respect to quality improvement data and committees; performs peer reviews on quality-of-care concerns.. · Possess skills in working across various organizational functional groups to achieve consensus and take into considerations all potential impacts of decision making in a matrixed environment.. · Other duties as assigned. Minimum Qualifications. · Graduation from an accredited medical school or school of osteopathy with an M.D. or D.O.. · Current board certification by the American Board of Medical Specialties (ABMS). · Current unrestricted clinical license to practice medicine in the states of Missouri and Kansas or ability to acquire as soon as offer extended and accepted. · No current sanction from Federal or State Governmental organizations; ability to pass credentialing requirements. · Ability to utilize technology efficiently in various platforms including all Microsoft products, various EMR’s, and other platforms.. · 2 years experience in performing utilization management activities, preferably a managed care setting but other UM activities considered. · The curiosity to continuously learn, the desire to innovate, the ability to demonstrate calm in the face of change, and the courage to act with integrity.. Preferred Qualifications. · MBA, MPH, or related management degree / training. · Experience with NCQA and URAC accreditation preparation and review. · Experience with Milliman Care Guidelines (MCG) and CMS policies. · Particular expertise and interest in pharmacy strategy / utilization. Blue Cross and Blue Shield of Kansas City - Today - save job. Get job updates from Blue Cross and Blue Shield of Kansas City. An independent licensee of the Blue Cross Blue Shield Association and a not-for-profit health insurance provider serving more than one mi.... Thousands of employers search for candidates on Indeed

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Keywords: Blue Cross and Blue Shield of Kansas City, Kansas City , Medical Director, Medicare Advantage / ACA, Other , Kansas City, Kansas

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