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Medical Director Utilization Management

BCBSM Career SectionDetroit🇺🇸United States

Quick overview

SeniorityLeader
Work modeHybrid
LocationDetroit, United States
Microsoft OfficeCPT Coding

Job description

Provide clinical expertise across the enterprise for various functions.  Responsible for corporate and medical policy interpretation, recommendation, and review within recognized areas of responsibility.  Advise and collaborate in the development of clinical programs.

  • Provide clinical support and participate in utilization management, quality management, and care management programs in respective area and identify opportunities for improvement and efficiency.
  • Assist in the design, development, implementation and assessment of disease state management and health enhancement programs that support the appropriate use of clinical resources in the delivery of consistent high-quality medical care.
  • Provide clinical leadership for health promotion and education programs and the claims editing department.
  • Assist in establishing corporate and regional programs to enhance quality of care, reduce medical costs and achieve positive health outcomes.
  • Serves as clinical resource and subject matter expert to both clinical and non-clinical staff.
  • Perform clinical reviews and conduct peer to peers.
  • Conduct discussions with physicians in the BCBSM network regarding: medical policies, utilization management, claims editing, use of resources and quality.
  • Perform high dollar claims and complex case reviews.
  • Participate in inter-rater reliability activities.
  • Participate in committees and workgroups to achieve department and corporate objectives.
    • "Qualifications"All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

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