Senior Medical Director

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.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

The Senior Medical Director is a senior level physician leader and a visible medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. This role is accountable for implementation and operational effectiveness of the medical management program within HNS and has responsibility for a personal (0.5 FTE) caseload of daily medical management activities. The role will have responsibility for training, coaching and mentoring a team of medical directors to execute on all required UM/CM/DM activities. The role will also be provider-facing and have accountability for assigned areas of NJ and assigned provider entities. The role will partner with the network management and clinical transformation teams to review provider performance, perform root cause analysis, develop corrective action plans, and support overall quality improvement of the network.

Medical Policy and HPIRT only:
The position oversees post-service reviews and medical reviews for the Clinical Inquiries Team (CIT).
The position is accountable for implementation and operational effectiveness of the Medical Policy/Code Integration/Medical Necessity Determinations within HNS and coordinates data analysis and provides leadership to the team in business process improvement initiatives expected to impact the efficiency and effectiveness of medical policy production and maintenance, code integration and maintenance.

Both areas are responsible for medical necessity determinations across all lines of business.

Responsibilities:

Medical Policy:

• Accountable for implementation and operational effectiveness of the Medical Policy/Code Integration/Medical Necessity Determinations within HNS Coordinates data analysis and provide leadership to the team in business process improvement initiatives expected to impact the efficiency and effectiveness of medical policy production and maintenance, code integration and maintenance and medical necessity determinations across all lines of business.

• Oversees post-service reviews and medical reviews for the Clinical Inquiries Team (CIT).

• Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI).

• Collaborate across functional areas which includes weekend coverage and assistance with appeals.  This will ensure compliance with company, state and federal guidelines.

Medical Management:

• Collaborates with and supports sales, Behavioral Health, Pharmacy, nursing staff, Medical Directors and staff from other functional areas to resolve and/or escalate issues. Establish and maintain relationships with hospitals, physicians and ancillary providers.

• Provide daily support across all lines of business for assigned medical management activities, including concurrent review, pre-certification, appeals, case management and other medical management activities as assigned. This includes weekend coverage and personal case management activities. Has responsibility for personal caseload of daily medical management activities (0.5 FTE) across all lines of business.

• Provide daily support for assigned medical management activities including medical necessity reviews, pre-determinations, appeals, code management, and other medical management activities as assigned.

• Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI).

Financial and Data Management

• Participate in the development and refinement of informatics reporting to support either the Regional Medical Management Program or Medical Policy Department and mentor MD/RN team members in data analysis and clinical decision making along with the development and implementation of action steps to improve financial and clinical outcomes.

• Responsible for ensuring that data analysis is accurate for assigned region and provides support to initiatives that impact quality metrics - Participates in development of corrective action steps to address variances to budget and/or plan.