Medical Director - Medicare Advantage

About the role

This role promotes and supports the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. It involves reviewing treatment procedures and services to ensure they comply with established guidelines or are supported by medical evidence. The role also includes providing direction to operations, facilitating committees, and addressing external contractual benefit issues.

Responsibilities

• Reviews treatment procedures and services to ensure compliance with established guidelines or medical evidence.
• Facilitates physician and provider committees as needed.
• Provides advice on external contractual benefit issues.
• Fulfills medical director duties as appropriate, including peer reviews, case reviews, and compliance with licensure requirements.
• Interacts with providers on programs like Performance Profiling, Disease State Management, Wellness, Medical Policy, and claims related issues.
• Reviews, provides medical expertise, and reports on utilization, case, and disease management activities.
• Participates in quality assurance efforts, accreditation activities, and other initiatives.
• Completes required training activities and complies with licensure and board certification requirements.
• Performs medical or administrative appeals based on medical policy, benefit language, or standard of care.

Requirements

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) required.
• 7 years of clinical practice experience, with 3 years of post-graduate experience in direct patient care.
• Prior detailed experience in utilization, case, or disease management in a hospital or health plan setting.
• Experience with external accreditation bodies like JCAHO, URAC, or NCQA.
• Medicare Advantage experience preferred.

Qualifications

• Current, unrestricted license to practice medicine in Louisiana.
• Board certification in a specialty recognized by ABMS.

Skills and Abilities

• Excellent communication, presentation, interpersonal, and human relations skills.
• Proficiency in Microsoft Office software (Word, Excel, Outlook, PowerPoint).

Benefits

Details about benefits are not provided in the given job posting.

Pay

Details about pay are not provided in the given job posting.

Schedule

Details about the schedule are not provided in the given job posting.

Skills

• Excellent communication, presentation, interpersonal, and human relations skills.
• Proficiency in Microsoft Office software (Word, Excel, Outlook, PowerPoint).

Benefits

Details about benefits are not provided in the given job posting.

Pay

Details about pay are not provided in the given job posting.

Schedule

Details about the schedule are not provided in the given job posting.

Accountabilities and Essential Functions

• Fulfills medical director duties as appropriate, including peer reviews, case reviews, and compliance with licensure requirements.
• Interacts with providers on programs like Performance Profiling, Disease State Management, Wellness, Medical Policy, and claims related issues.
• Reviews, provides medical expertise, and reports on utilization, case, and disease management activities.
• Participates in quality assurance efforts, accreditation activities, and other initiatives.
• Completes required training activities and complies with licensure and board certification requirements.
• Performs medical or administrative appeals based on medical policy, benefit language, or standard of care.