Medical Director - Medicaid

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.

This position is remote/hybrid within the state of AZ only

PURPOSE OF THE JOB

Direct, lead and provide professional oversight for medical management and population health activities related to utilization management, case and care management, disease management, performance improvement, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals in compliance with AHCCCS and CMS regulations, to advance timely access to high quality care and services, and to ensure that medical policies, procedures and the

activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 3 years of experience in a clinical setting

· 1 year of experience in physician leadership role, including quality review, utilization review, population health and other managed care functions

2. Required Education

· Medical Degree

3. Required Licenses

· Active, current, and unrestricted license to practice medicine in the State of Arizona (a state in the United States).

4. Required Certifications

· Board Certification

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 3 years of experience in a primary care or medical specialty field

· Additional experience with population health and/or medical management, with preference for experience serving Medicaid members

· Knowledge of NCQA accreditation standards for health plans

2. Preferred Education

· Physician leadership, medical management, or population health coursework and training

3. Preferred Licenses

· N/A

4. Preferred Certifications · N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

· Provide direction, support, and medical expertise and oversight to areas within the Clinical Services and Quality Divisions including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis and performance improvement, prior authorization review, dispute resolution, regulatory compliance (including NCQA, CMS, and Medicaid), care and disease management, concurrent review, medical claims reconsideration and retrospective review, and related medical management and population health functions.

· Provide consultative services throughout the organization, as requested and related to the specific medical director role.

· Communicate with members, providers, and external stakeholders and collaborators regarding policies, processes, and specific situations and cases, including recommendations and showing the impact of BCBSAZ interventions.

· Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs and administrative expense, increase quality of care and service, improve provider and member satisfaction, and advance health equity.

· Review, advise on, and implement medical policies and other medical decision-making policies or procedures

· Represent BCBSAZ at professional organizations, act as liaison with individual health care professionals, and support collaborative relationships with physicians and hospitals.

· Provide professional oversight for and/or participation in various committees including, but not limited to the Medicaid segment Quality Management and Performance Improvement Committees, Credentialing Committee, Peer Review Committee, and Population Health/Medical Management Committee.

· Participate in the appeals and grievance processes, as appropriate, to ensure timely and accurate responses to members and providers

· Conduct, as appropriate, Appeal Peer Review cases in accordance with required qualifications.

· Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.

· Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care.

· Provide leadership to staff and other professionals through clinical excellence, professional behavior and innovative thinking.

· Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.

· Identify opportunities to achieve administrative efficiencies while maintaining high quality service.

· Maintain and promote effective working relationships to ensure teamwork in achieving corporate goals.

· Contribute to departmental and cross-functional teamwork to achieve BCBSAZ goals and ensure future success.

· Coordinate activities, as appropriate, between multiple divisions to achieve desired results.

· The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

· Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

2. Required Job Skills

· Strong written and verbal communications.

· Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.

· Intermediate skill in word processing, spreadsheet and database software.

· Intermediate PC proficiency.

3. Required Professional Competencies

· Interpersonal skills that allow for harmonious relationships with providers, members and coworkers

4. Required Leadership Experience and Competencies

· N/A

PREFERRED COMPETENCIES

1. Preferred Job Skills

· Familiarity with NCQA accreditation standards

· Previous experience with AHCCCS and/or state Medicaid or D-SNP programs

2. Preferred Professional Competencies

· N/A

3. Preferred Leadership Experience and Competencies

· N/A

Our Commitment

BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona.  For more information on our company, see azblue.com.  If interested in this position, please apply.