Blue Cross Blue Shield of Michigan

Nonprofit mutual insurer administering health benefits

Medical Director - Medical Policy

Physicians & SurgeonsConfirmed live in the last 24 hours

Full-timeDetroit, MI, USANo salary listedIn-person

About the Job

Requirements

A Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.) doctorate from an accredited school of medicine is required.
Seven years of clinical practice experience is required.
A current unrestricted Michigan Doctor of Medicine or Doctor of Osteopathy license is required.
Board certification or board eligibility, with ongoing work toward certification, is required in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
Proven leadership and problem-solving skills, with the ability to manage multiple priorities, are required.
Strong teaching and communication skills are required.
The ability to take ownership of initiatives and collaborate with cross-functional teams to achieve department and corporate goals is required.
Demonstrated skill with Microsoft Office Suite and web-based programs is required.
Understanding of health plan functions related to utilization, care, and quality management is required.

Responsibilities

Develop and maintain medical policy, including establishing the rationale for approving inquiries and appeals.
Assist with clinical research, write documents, and document decisions.
Provide utilization management for prior authorization procedures and review cases to make decisions based on medical policy.
Provide clinical support to various areas of the organization by processing requests for clarification, interpretation, or questions about policy or benefits and reviewing potential impacts of clinical matters.
Serve as a clinical resource and subject matter expert to clinical and non-clinical staff.
Perform clinical reviews and conduct peer-to-peer consultations.
Participate in JUMP committee meetings.

Desired Qualifications

Specialty care knowledge is preferred.
Medical policy experience is a plus.

Provides clinical program leadership and develops, implements and approves policies within recognized area of responsibility.

Develop and maintain medical policy. Establish rationale for approving inquires and appeals.
Assists with clinical research, writing documents, and documenting decisions.
Provide utilization management for prior authorization procedures. Review cases and make decisions based on medical policy.
Provide clinical support to various areas of the organization. Process requests for clarification, interpretation, or questions about policy or benefits. Review potential impacts of clinical matters.
Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
Perform clinical reviews and conduct peer to peers.
Participate in JUMP committee meetings.

"Qualifications"

Doctorate from an accredited school of medicine (M.D.) or osteopathy (D.O) required.
Seven (7) years clinical practice experience.
Current unrestricted state of Michigan Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license.
Board certified or board eligible and working towards certification in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy.
Proven leadership, problem solving, and the ability to manage multiple priorities.
Strong teaching and communication skills.
Results oriented and the ability to take ownership for initiatives and collaborate with cross-functional teams to achieve department and corporate goals.
Demonstrated skill with Microsoft Office Suite and web-based programs.
Understanding of health plan functions related to utilization, care, and quality management.
Other related skills and/or abilities may be required to perform this job.

Department Summary / Preferences:

Specialty Care Knowledge is preferred.

Medical Policy Experience is a plus.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

About the Company

Blue Cross Blue Shield of Michigan

Nonprofit mutual insurer administering health benefits

Nonprofit mutual insurer Blue Cross Blue Shield of Michigan administers health benefits for more than 4.3 million members in Michigan and across the United States. It offers group health plans for businesses of various sizes, including a private exchange that lets employers provide a selection of market-leading benefits, plus life and disability insurance. It operates through employer-sponsored plans and a network-based coverage model, with tailored plans and benefits administration. Its goal is to keep health care costs affordable and predictable for individuals and employers while providing broad access to coverage nationwide as an independent licensee of the Blue Cross Blue Shield Association.

Company size: 10,001+
Company stage: Not listed
Total funding: Not listed
Headquarters: Detroit, MI
Founded: 1938

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