Medical Director

We need to output HTML fragment with sections for headings: About the role, Responsibilities (maybe "What You'll Do"), Requirements/Qualifications, Skills, Benefits, Pay, Schedule. Only include sections if posting has real specific content. We must not repeat job title. Must not include Job ID etc. Remove boilerplate. Must preserve all substantive info. We need to parse the posting. Key sections: - About The Role: description after "About The Role". Contains paragraph about Medical Director responsibilities. - What You'll Do: list of duties. - What You Bring: functional competencies, knowledge etc. - Qualifications: list. - Knowledge, Skills And Abilities: list of skills. - Travel % (If Applicable): mention travel requirement. - Why Horizon?: description about company culture. - Salary Range: $214,100 - $297,885 (Pay section). Also mention benefits: "Horizon also provides a comprehensive compensation and benefits package which includes: Comprehensive health benefits (Medical/Dental/Vision)Retirement PlansGenerous PTOIncentive PlansWellness ProgramsPaid Volunteer Time OffTuition Reimbursement". That's Benefits. - Schedule? Not mentioned explicitly. No schedule info. So we should not create Schedule section. - Also there is "Travel % (If Applicable): The position requires access to a car and the ability to travel for meetings with physicians, hospitals and ancillary providers as required." That's travel requirement; could be part of Responsibilities or a separate section? Not a standard heading; but we could include under Responsibilities or maybe a "Travel" subsection but not required headings. Since only allowed headings are those listed, we could incorporate travel info into Responsibilities or maybe under "What You'll Do". Probably include in Responsibilities. - Also there is "Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware." That's location requirement; could be part of Qualifications? Might be considered a requirement. Could include under Qualifications or Requirements. We'll include as a bullet under Qualifications maybe. - Also "This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification." That's boilerplate; remove. - Also EEO statement; remove. - Also "Horizon will consider reasonable accommodation requests..." remove. - Also "Medical Policy And HPIRIT Only:" sections appear duplicated; we need to preserve substantive info but not duplicate. The content under that heading includes: "Performs medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed", "Support development and implementation of reimbursement policies", "Assist with coverage across functional MD teams as needed including participation in calls for all areas". Some of these already appear elsewhere. We need to preserve but avoid duplication. We'll incorporate unique info. Let's extract substantive content: About The Role paragraph: "The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, disease management, quality management, pharmacy management, post service reviews, provider education, support for provider relations issues, and clinical transformation. The Medical Director is accountable for a personal caseload of daily medical management activities and contributing to operational effectiveness of the medical management program. Medical Policy And HPIRIT Only: The position has primary responsibility for the medical review for the Clinical Inquiries Team (CIT) and support special investigations unit as needed. Also, the position supports the development and implementation of reimbursement policies." We'll keep that. What You'll Do bullet list: - Support all lines of business which includes Commercial and Government Programs. - Collaborate with value based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable. - Supports sales teams as assigned by region. - Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable. - Consult with/support case management to determine best course for members, assist with PG and address issues. - Develops and maintains effective collaborative relationships with providers in assigned geographic areas. This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers. May provide input into provider credentialing, profiling and communication initiatives. - Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management. - Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix. - Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region. - Assists with assessment of network capabilities by region and collaborates with network management, contracting and value based teams in addressing network gaps. - Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas. - Participates in Committee activities as assigned. - Assist with coverage across functional MD teams, as needed, including participation in calls for all areas. - Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team. - Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI). - Backup chair for committees with internal and external stakeholders - Medical Policy And HPIRIT Only: Performs medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed - Support development and implementation of reimbursement policies - Assist with coverage across functional MD teams as needed including participation in calls for all areas We need to deduplicate: many items repeat. We'll consolidate unique duties. Let's list unique duties: 1. Support all lines of business (Commercial and Government Programs). 2. Collaborate with value based teams, Behavioral Health and Pharmacy; support accounts and activities for cross functional areas by region. 3. Support sales teams as assigned by region. 4. Guide, support, consult with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions. 5. Consult/support case management to determine best course for members, assist with PG and address issues. 6. Develop and maintain effective collaborative relationships with providers in assigned geographic areas (on-site/virtual performance review, coaching; input into provider credentialing, profiling, communication initiatives). 7. Responsible for data analysis on case management and utilization; identify issues and escalate to senior management. 8. Interpret and analyze utilization, cost, quality reports; develop steps to address variances to target performance matrix. 9. Collaborate on documentation of monthly reporting (performance, issues, activities) for assigned region. 10. Assist with assessment of network capabilities by region; collaborate with network management, contracting, value based teams to address network gaps. 11. Create/participate in internal or external educational activities for team/stakeholders across regional/functional areas. 12. Participate in Committee activities as assigned. 13. Assist with coverage across functional MD teams as needed, including participation in calls for all areas. 14. Support medical policy development process; review medical and pharmacy policies; provide feedback regarding utilization to development team. 15. Work with legal and mandate team to support Horizon’s compliance with NJ DOBI. 16. Backup chair for committees with internal and external stakeholders. 17. Perform medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed. 18. Support development and implementation of reimbursement policies. Also mention travel requirement: "The position requires access to a car and the ability to travel for meetings with physicians, hospitals and ancillary providers as required." Could be added as a duty. Now What You Bring (Functional Competencies): - Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards. - Requires broad clinical knowledge and understanding of current health care issues and climate. - Requires some knowledge of health insurance payer business including business operations. Qualifications: - Requires Board Certification in an American Board of Medicine recognized specialty. - Requires current unrestricted MD or DO license to practice medicine. - Requires 5-7 years Clinical Experience. - Experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management. - Proficiency working with Tableau or similar software required. - Proficiency also required working with a Windows based environment including MS Office products. - Continuous Improvement Experience Preferred. - Specific To Medical Policy: Ability to review studies, understand evidence based medicine and support medical policy development. - Ability to chair committees with internal and external stakeholders. - 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. Knowledge, Skills And Abilities: List: - Business Acumen: Identify key issues and opportunities, developing strategies and plans and have resolute decision making. - Planning and Organizing: Leveraging resources, staying focused and effectively prioritizing key objectives. - Building Strategic Working Relationships: Proactively tries to build effective working relationships; facilitates agreement; clarifies current situation; involving appropriate individuals within team and broader organization to achieve desired results. - 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. - Meeting Leadership: Ensures a meeting serves its business objectives; facilitating agreement; develops others' and own ideas; closes discussions with clear summaries. - Negotiation: Effectively exploring alternatives and positions to reach outcomes that gain the support and acceptance of all parties. - Matrix Environment: Ability to function and work in a matrix environment which includes working on and at time leading cross functional teams. - Conflict resolution: ability to identify conflict, determine its causes and negotiate mutually agreeable solutions. Travel %: mention travel requirement. Why Horizon?: paragraph about meaningful work, mission-driven, etc. Salary Range: $214,100 - $297,885. Benefits: Comprehensive health benefits (Medical/Dental/Vision), Retirement Plans, Generous PTO, Incentive Plans, Wellness Programs, Paid Volunteer Time Off, Tuition Reimbursement. Also note: "Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware." That's a location requirement; could be added under Qualifications as a bullet. Now we need to output HTML with headings

for each section we include. We should not include empty sections. We'll include: - About the role (

About the role

) - Responsibilities (

Responsibilities

) (using What You'll Do) - Qualifications (

Qualifications

) - Skills (

Skills

) (maybe combine Knowledge, Skills And Abilities) - Benefits (

Benefits

) - Pay (

Pay

) (Salary Range) - Maybe Travel? Not a standard heading; we could incorporate travel into Responsibilities or Qualifications. Let's add a bullet under Responsibilities: "Requires access to a car and ability to travel for meetings with physicians, hospitals, and ancillary providers as required." We'll not include Schedule. We'll not include "Why Horizon?" as it's not a standard heading; but could be considered "About the company" but not in list. The instruction says use headings for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we should not add other headings. So we should incorporate "Why Horizon?" maybe into a paragraph under About the role? But it's about company culture; maybe we can put it under a generic

after the headings? The instruction says output only HTML fragment; we can include

sections not under headings? It says use

for section headings,

• for any list,

  for prose. So we can have prose paragraphs