Medical Director (Kansas City)

Medical Director

Provides medical leadership and physician advice for the Medical Management function. Additionally, provides leadership and advice to other divisions of BCBSKC and to the community.

Provides prime management oversight and development for a major program or functional area within Medical Management, e.g., medical policy, credentialing, utilization management, case management, patient centered medical home, population management, reporting capability, etc. Acts as senior clinical staff person for credentialing or utilization management program, and provides guidance for clinical operational aspects and quality improvement for these programs. Chairs committee of practitioners in the field (Credentialing, Peer Review, or Medical and Pharmacy Management Committee).

Improves the quality and efficiency of care in the network and integrate providers into BlueKC clinical initiatives by providing direction to physicians and other providers, Provides utilization management for medical, surgical and pharmacy activity.

Participates in medical appeals activity. Reviews all 2nd-level overturned cases related to medical necessity / investigational issues in the context of potential medical policy updates.

Serves as expert / resource on appeals related to utilization management issues.

The following Essential Accountabilities are common to board certified and non-board certified Medical Directors :

Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees. Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals.

Serves as physician advisor for other areas within the company, including but not limited to Sales and Marketing, Job_Family_ID_Underwriting, PHP, Special investigations Unit (fraud and abuse), Legal, Product Development, and Provider Services.

Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies.

Acts as liaison for communication with physicians, hospitals, and other providers in the community.

Reviews customer service and claims inquiries.

Minimum Qualifications :

• M.D. or D.O. degree from an accredited medical school required.
• 5 + years or experience in direct clinical patient care post-residency or fellowship training.
• Board certification in an approved American Board of Medical Specialties (ABMS) specialty with continued certification throughout employment required
• Experience with quality improvement and utilization improvement work / projects
• Excellent verbal and written communication skills
• Knowledge of the managed care industry including Medicare Advantage, Managed Medicaid and / or Commercial products, or other medical management organizations, hospitals / Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management
• Current unrestricted medical license to practice medicine in the states of Missouri and Kansas or willingness to obtain upon hire required
• Experience working with Case managers or Care managers on complex case management, including familiarity with social determinants of health
• Desire to continuously learn, display the flexibility to adapt to changes, and demonstrated success in being part of a larger team

Preferred Qualifications :

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.