Senior Medical Director - CBU

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.

About the Role

The Senior Medical Director supporting the Commercial Business Unit (CBU) serves as the primary physician leader and clinical liaison for CBU clinical engagements. The role provides clinical credibility, timely medical expertise, and actionable recommendations that help make healthcare work for CBU’s customers while strengthening relationships, supporting client retention and growth, and translating complex clinical topics into practical, client-ready discussions.

Responsibilities

• Client and Market-Facing Clinical Leadership
  • Serve as the Medical Director attendee and presenter for the Board, annual and biannual performance meetings with Horizon’s CBU customers, including national account and ASO clients.
  • Participate in finalist, broker, prospective clients, existing customers, and internal account team preparation and presentations.
  • Build and maintain productive relationships with external Medical Directors representing CBU customers, clinical teams working for brokers and consultants, and NJ DOBI contacts on clinical issues.
  • Use client profiles and account background materials to tailor clinical discussion, anticipate questions, and present complex clinical information in a clear, client-friendly manner.
  • Attend customer status calls with Account Managers or Account Executives when clinical expertise is needed.
• Clinical Escalations, Appeals and Performance Guarantees
  • Provide clinical expertise on escalated customer inquiries and appeals, supporting the committed three-business-day turnaround expectation for clinical escalations.
  • Speak directly with network providers, as appropriate, to address authorization-related escalations in support of CBU’s customers.
  • Provide clinical expertise related to audits and performance guarantees.
• Medical Policy, Coding and Cost Optimization
  • Act as the liaison between the Medical Policy Committee and the CBU teams on medical policy changes that could impact CBU clients.
  • Bring medical policy-related concerns voiced by CBU clients to the appropriate committee or forum for review and resolution.
  • Support clinical coding updates and coding changes requested by, or impacting, CBU clients.
  • Develop, participate in, and communicate medical cost optimization programs that impact CBU clients.
  • Provide recommendations for internal process updates based on customer feedback and recurring clinical issues.
• Cross-Functional Resource Planning and Meeting Support
  • Partner with CBU Account Executives, Pharmacy, Analytics, Care Management, and administrative support to coordinate annual wrap-up, finalist, and client-facing meeting support.
  • Coordinate with Analytics on outcomes reporting needed for client meetings.
  • Partner with Nurse Case Managers to complete interdisciplinary rounds for clients with performance guarantees related to case management activity.
• Program, Audit and Vendor Support
  • Participate in and provide support for clinical audits of Horizon Care Navigator, Care Management Plus, High-Cost Claimant, and related programs.
  • Work closely with Horizon Care Navigator, Horizon Care Management Plus, and Pharmacy teams to provide clinical insight on cases.
  • Clinically vet vendors requested by, or offered to, clients and provide recommendations on suitability, clinical value, and alignment with client needs.
  • Hold accountability for budget management of specialty match spend on utilization management reviews for clients.
  • Participate in association and consortium workgroups related to medical policy, quality, cost containment, population health, and sales, as applicable.

Requirements

• MD or DO degree with active, unrestricted medical license; board certification is strongly preferred.
• Minimum 5 years of clinical practice experience.
• Minimum 3 years of experience in managed care.
• Experience with account management, sales, analytics, pharmacy, utilization or care management, medical policy, broker/consultant, or regulatory-facing teams is preferred.
• American Board of Medical Specialties (ABMS) board certification.

Qualifications

• Significant clinical leadership experience in managed care, health plan, payer, employer group, population health, or related healthcare environment.
• Demonstrated ability to communicate complex clinical, utilization management, medical policy, pharmacy, and cost containment topics to non-clinical audiences.
• Proficiency working with a Windows-based environment including MS Office products.
• Knowledge of clinical operations within a managed care organization.
• Knowledge of Commercial health insurance products.

Skills

• Clinical judgment and credibility.
• Client-centric communication and relationship management.
• Enterprise collaboration and cross-functional influence.
• Strategic thinking with practical execution discipline.
• Data-informed decision making and resource planning.
• Accountability, responsiveness, and attention to commitments.
• Ability to simplify complexity for executive, client, and account team audiences.
• Adept at influencing and challenging senior management and staff.
• Ability to manage and lead through influence in a highly matrixed environment.
• Ability to present and interact with senior leadership or clients as necessary.
• Ability to tailor communication and messages to diverse audiences.
• Advocates for the organization, inspiring confidence among peers regarding reliability and capability.
• Ability to develop Horizon BCBSNJ staff’s competencies related to medical cost optimization (MCO) and executive decision-making skills.
• Ability to exercise independent judgment in making decisions.
• Ability to interpret and apply state and federal regulations, hospital and provider contracts, and medical policy to provide guidance related to MCO.
• Effective verbal and written communication and presentation skills.
• Proven ability to innovate, be goal-oriented, possess strong critical thinking skills, and exercise sound judgment.
• Experience with utilization management, quality, payment integrity, case management, and/or medical policy.
• Broad clinical skills to understand medical issues.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision).
• Retirement Plans.
• Generous PTO.
• Incentive Plans.
• Wellness Programs.
• Paid Volunteer Time Off.
• Tuition Reimbursement.

Pay

Salary Range: $240,200 - $334,110. This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.