Job description
Provides medical guidance and support to the full spectrum of Capital’s Clinical Utilization Management activities and programs. Supports appropriate Utilization Management goals and objectives.
Provides professional leadership and direction to the functions within the Utilization Management Department.
Provides professional leadership and direction to the functions within the Utilization Management Department.
Duties and Responsibilities:
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
- Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
- Engage with requesting providers as needed in peer-to-peer discussions
- Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
- Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
- Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation.
- Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
- Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director.
- Supports organizational accreditation efforts and regulatory review processes: Prior- Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs. .
- Performs other related duties and assignments as directed.
Skills:
- Demonstrated public speaking and written communication skills.
Knowledge:
- Knowledge of current and emerging medical treatment modalities.
- Familiarity with National Committee for Quality/URAC standards.
Experience:
- A minimum of five years clinical experience, post residency, including both inpatient and outpatient care.
- At least three years’ experience in managed care, utilization review, and/or quality management.
Education and Certifications:
- Minimum requirements include an MD or DO Degree, as well as appropriate Board Certification.
- Current unrestricted licensure in Pennsylvania as an MD or DO.
- Currently covered by, or eligible to be covered by, medical liability insurance.
Physical Demands:
While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.
Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.
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