Lead Medical Director

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include :

Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute

Annual incentive bonus plan based on company achievement of goals

Time away from work including paid holidays, paid time off and volunteer time off

Professional development courses, mentorship opportunities, and tuition reimbursement program

Paid parental leave and adoption leave with adoption financial assistance

Employee discount program

Job Description Summary :

The Lead Medical Director actively uses their clinical training, experience, and judgement to make determinations whether requested services, requested level of care, and / or requested site of service should be authorized. The Medical Director will apply various clinical policies, state and federal guidance, and contracts in decision making. Will provide expertise from a clinical perspective for various organizational projects and inquiries and be a leader in providing clinical guidance in a variety of activities. As well as supporting and heading a small team of Medical Directors.

Job Description

• Provide computer-based clinical reviews of moderately complex to complex clinical scenarios to include a review of all submitted clinical records, external telephonic conversations with the providing physician in the form of Peer-to-Peers, and close collaboration with the nursing team.
• Able to review at overall data to then inform strategy around continuous improvement of healthcare delivery as well as individual decision making.
• Demonstrate critical thinking skills in decision making by applying the correct guidelines in the greater context of delivering the best quality of care to members while achieving cost efficiency.
• Display ability to have active listening skills, ask key questions, and demonstrate compassion towards all parties when making decisions that may not have universal agreement, particularly around utilization review activities.
• Review individual member experiences to identify where care gaps exist and identify resources (external and internal), participate in group rounds to discuss complex cases from a holistic perspective, and assure that evidence-based guidelines are driving care decisions.
• Possess a broad base of medical knowledge but also a willingness to learn and expand clinical acumen to provide decision making across all medical specialties as well as having a collaborative approach to seek additional input where needed to arrive at the best decision.
• Improves the quality and efficiency of care in the network and integrates providers into Blue KC 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 appealed 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.
• 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, Special investigations Unit (fraud and abuse), Legal, Product Development, Compliance 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

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.