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 Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, disease management, quality management, pharmacy management, post service reviews, provider education, support for provider relations issues, and clinical transformation. The Medical Director is accountable for a personal caseload of daily medical management activities and contributing to operational effectiveness of the medical management program.

Medical Policy and HPIRIT only:
The position has primary responsibility for the medical review for the Clinical Inquiries Team (CIT) and support special investigations unit as needed. Also, the position supports the development and implementation of reimbursement policies.

Responsibilities:

• Support all lines of business which includes Commercial and Government Programs.

• Collaborate with value based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable. Supports sales teams as assigned by region.

• Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable. Consult with/support case management to determine best course for members, assist with PG and address issues.

• Develops and maintains effective collaborative relationships with providers in assigned geographic areas. This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers.

• May provide input into provider credentialing, profiling and communication initiatives.

• Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management.

• Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix. Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region.

• Assists with assessment of network capabilities by region and collaborates with network management, contracting and value based teams in addressing network gaps.

• Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas.

• Participates in Committee activities as assigned.

• Assist with coverage across functional MD teams, as needed, including participation in calls for all areas.

• Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team.

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

• Backup chair for committees with internal and external stakeholders.

Medical Policy and HPIRIT only:

• Performs medical reviews for the  Clinical Inquiries Team (CIT) and support special investigations unit as needed.

• Support development and implementation of reimbursement policies.

• Assist with coverage across functional MD teams as needed including participation in calls for all areas.

Functional Competencies:

• Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards.

• Requires broad clinical knowledge and understanding of current health care issues and climate.

• Requires some knowledge of health insurance payer business including business operations.

Education/Experience:

• Requires Boa