Medical Director (Medicaid Segment) - Remote-AZ

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Direct, lead and provide professional oversight for medical management activities related to utilization management, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community. QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 3 years of experience in a clinical setting 1 year of experience in physician leadership role, including quality review, utilization review and other managed care functions Required Education Medical Degree Required Licenses Active, current, and unrestricted license to practice medicine in the State of Arizona (a state in the United States) Required Certifications Board Certification PREFERRED QUALIFICATIONS Preferred Work Experience 3 years of experience in a primary care field Preferred Education N/A Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review. Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions. Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions. Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense. Review, and implement medical policies and other medical decision making policies or procedures Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals. Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee. Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers Individuals who conduct a clinical peer review must possess a license or certification in a health profession that is: Of the type and scope that permits them to apply their clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination For either a Doctor of Medicine or Doctor of Osteopathic Medicine; or is the same license or certification as the ordering practitioner Knowledgeable of the issue under review, or of the current, evidence-based clinical guidelines and novel treatments for the medical or behavioral health condition, disease, treatment, or procedure under review Qualified to render a clinical opinion or determination about the medical or behavioral health condition, procedures, and treatment under review Conduct, as appropriate, Appeal Peer Review cases in accordance with the required qualifications. Provide written information to members and providers through letters and articles in member and provider newsletters and other publications. Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care. Provide leadership to staff and other professionals through clinical excellence, professional behavior, and innovative thinking. Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies. Identify opportunities to achieve administrative efficiencies while maintaining service. Maintain effective working relationships to ensure teamwork in achieving corporate goals. Contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success. Coordinate activities between multiple divisions to achieve desired results. The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. COMPETENCIES REQUIRED COMPETENCIES Required Job Skills Strong written and verbal communications. Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones. Intermediate skill in word processing, spreadsheet and database software. Intermediate PC proficiency. Required Professional Competencies Interpersonal skills that allow for harmonious relationships with providers, members and coworkers Required Leadership Experience and Competencies N/A PREFERRED COMPETENCIES Preferred Job Skills N/A Preferred Professional Competencies N/A Preferred Leadership Experience and Competencies N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see . If interested in this position, please apply.