Senior Medical Director

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

Responsibilities:

Medical Policy:

• Accountable for implementation and operational effectiveness of the Medical Policy/Code Integration/Medical Necessity Determinations within HNS Coordinates data analysis and provide leadership to the team in business process improvement initiatives expected to impact the efficiency and effectiveness of medical policy production and maintenance, code integration and maintenance and medical necessity determinations across all lines of business.

• Oversees post-service reviews and medical reviews for the Clinical Inquiries Team (CIT).

• Works with legal and mandate team to support Horizon's compliance with the NJ Department of banking and insurance (DOBI).

• Collaborate across functional areas which includes weekend coverage and assistance with appeals. This will ensure compliance with company, state and federal guidelines.

Medical Management:

• Collaborates with and supports sales, Behavioral Health, Pharmacy, nursing staff, Medical Directors and staff from other functional areas to resolve and/or escalate issues. Establish and maintain relationships with hospitals, physicians and ancillary providers.

• Provide daily support across all lines of business for assigned medical management activities, including concurrent review, pre-certification, appeals, case management and other medical management activities as assigned. This includes weekend coverage and personal case management activities. Has responsibility for personal caseload of daily medical management activities (0.5 FTE) across all lines of business.

• Provide daily support for assigned medical management activities including medical necessity reviews, pre-determinations, appeals, code management, and other medical management activities as assigned.

• Works with legal and mandate team to support Horizon's compliance with the NJ Department of banking and insurance (DOBI).

Financial and Data Management

• Participate in the development and refinement of informatics reporting to support either the Regional Medical Management Program or Medical Policy Department and mentor MD/RN team members in data analysis and clinical decision making along with the development and implementation of action steps to improve financial and clinical outcomes.

• Responsible for ensuring that data analysis is accurate for assigned region and provides support to initiatives that impact quality metrics - Participates in development of corrective action steps to address variances to budget and/or plan.

Leadership

• Provide leadership and management support for the successful development, implementation, and ongoing operationalization of either the Regional Medical Care Management model of care or Medical Policy Department. This includes playing a leadership role in MD and RN education and development with regard to criteria application, documentation, accreditation and regulatory requirements.

• Responsible for coaching, mentoring and providing clinical direction for the team as well as providing daily oversight for coordination and adjustment of MD/Clinician schedules and assignments to ensure medical management coverage needs are met. This includes on call and weekend coverage.

Functional Competencies:

• Requires knowledge of utilization management, case management, quality management and network management.

• Requires knowledge of accreditation requirements, NCQA, development of evidence based medical policies and criteria, CMS requirements, informatics, and provider profiling.

• Requires knowledge of group health insurance industry.

• Requires experience or knowledge of facility, provider and ancillary contracting.

• Requires broad clinical skills to understand medical issues.

• Requires knowledge and education of Commercial and Government Program lines of business.

Education/Experience:

Additional licensing, certifications, registrations:

• Active Unrestricted MD or DO License Required; NJ License Required, No CMS Sanctions or sanctions by other regulatory agencies or boards.

• Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.

• Influence both senior management and direct reports.

• Ability to challenge senior management as needed.

• Manage in a matrix environment.

• Developing Self and Others - Must be able to develop staff and leverage team capabilities for optimal outcomes.

• Communicate with Impact - Must be able to present and interact with senior leadership as necessary.

• Adaptability - Must be able to tailor communication and messages to diverse audiences.

• Executive Presence: Advocates for the organization, inspiring confidence among peers regarding reliability and capability, inspiring senior leadership expectations on potential for outstanding outcomes and achievements.

• Develop Medical Director competences related to network management and executive decision making skills.

• Requires the ability to exercise independent judgment in making medical necessity decisions.

• Requires the ability to interpret and apply medical policy and provide guidance to others.

• Must have effective verbal and written communication and presentation skills and demonstrate the ability to work well within a team.

• Requires proven ability to be innovative, goal oriented, possess strong problem solving skills and exercise sound judgment.

Travel % (If Applicable):

• Travel within NJ/NY/PA required as needed.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.