Medical Director (Hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue 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.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least once per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per month.

PURPOSE OF THE JOB

• Direct, lead and provide professional oversight for medical management activities related to utilization management, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals 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

• 3 years of experience in a clinical setting
• 1 year of experience in physician leadership role, including quality review, utilization review and other managed care functions

• Medical Degree

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

• Board Certification

PREFERRED QUALIFICATIONS

• 3 years of experience in a primary care field

• N/A

• N/A

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review.

• Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions.
• Communicate with customers regarding their difficult and costly 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, increase quality of care and service, and reduce administrative expense.
• Review, and implement medical policies and other medical decision-making policies or procedures
• Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals.
• Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee.
• Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers
• Conduct, as appropriate, Appeal Peer Review cases in accordance with the required qualifications.
• Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.
• Work to ensure prod