MEDICAL DIRECTOR

At Horizon Blue Cross Blue Shield of New Jersey, the collaboration between diverse professionals is one reason people are making NJ's largest health insurer their favorite place to work. With more than 3.8 million members, our goal is to provide individuals and employers in New Jersey with convenient access to quality, affordable health care.

MEDICAL DIRECTOR

Hopewell, NJ

In this role, you will be accountable for providing day-to-day guidance, support and medical leadership for utilization and quality management activities and decisions. You will also be responsible for analyzing data from a variety of sources to identify trends and/or issues.

Responsibilities:

• Provides medical expertise based on extensive knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols.
• Supports guides and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues or decisions.
• Supports guides and consults with nurse reviewers on case management issues or decisions.
• Supports guides and consults with nurse reviewers on medical necessity and medical appropriateness issues or decisions.
• Participates in the development, planning and management of complex cases and communicates management plan to the provider.
• Guides staff in the interpretation of medical policy. Assists in Medical policy and technology assessments and recommendations.
• Assists or consults on appeal review process.
• May provide input to provider credentialing, profiling and communication initiatives and network development.
• Participates on various internal or external committees as assigned.

Knowledge:

• Requires knowledge in the principles and procedures of Utilization Management, the URAC Health UM Standards and peer review.
• Requires excellent understanding of the principles and concepts of managed care.
• Requires knowledge of the health insurance payor business, including operations.
• Requires broad clinical knowledge and understanding of current health care issues.

Skills and Abilities:

• Requires broad clinical skills to understand medical issues and to discuss them with physicians.
• Requires the ability to exercise independent judgement in making medical necessity decisions.
• Requires the ability to interpret and apply medical policy and provide guidance to others.
• Requires strong communication skills.
• Requires analytical skills to evaluate data from various sources to identify trends and issues.

Education:

• Requires board certification as an MD or DO with a current unrestricted license to practice medicine in one of the primary care specialties.

Experience:

• Requires a minimum of five years clinical experience as well as three or more years’ medical management in a managed care setting.

Special Licenses and Certifications:

• Requires an active and unrestricted New Jersey MD or DO license.
• Requires current board certification in one of the primary care specialties.

We offer a highly competitive salary, dynamic work environment, and a comprehensive benefits package. For immediate consideration, please apply online and reference job requisition #PKR052019-13170 at: www.HorizonBlue.com/Careers.

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, 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
Blue Cross Blue Shield of New Jersey

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