Associate Medical Director

Job Description

What You'll Do

The application of a Medical Director's knowledge and clinical skills will vary across the Health Care division, dependent on focus areas identified by the business areas supported.

• Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members
• Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care
• Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process
• Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management
• Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements
• Reviews quality referred issues, focused reviews and recommends corrective actions
• Develops and implements plan medical policies
• Supports population health
• Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care
• Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care
• Ensures that medical protocols and rules of conduct for plan medical personnel are followed
• Provides clinical expertise in support for quality improvement, sales, account, technology, investment and community engagement activities
• Works with Contracting Department in contract negotiation

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Leadership Skills:

• Project planning and management

Core Skills:

• Strategy
  • Develops, collaborates and/or drives strategy and approach for varied Health Care and/or organizational initiatives (i.e. sales management strategies, behavioral health strategies, new health care delivery strategies)

• Operations
  • Medical reimbursement and policy
  • Care management (utilization management, case management, PA, appeals)
  • Healthcare programs (disease management, Moonshots)
  • Network support (Credentialing)
  • Quality model design and analysis

• Partnership
  • Develop strategic partnerships with internal business partners and external clients to support value-based agreements and drive better consumer and provider experience.
  • Takes a lead role in outreach and relationship building across the community (i.e. providers, health systems, community partners, members, etc).
  • Evaluate and manage new and/or existing vendors and solution partners to align to BCNC’s strategic direction
  • Ongoing provider engagement functions

• Data gathering, management and analysis
  • Evaluate clinical and other data to identify opportunities for improvement in health outcomes and financial performance
  • Discuss data and performance with providers, employers, accreditors and regulators as needed.

• Communications
  • Represent BCNC through delivery of presentations, speaking engagements and leadership of advisory groups with external audiences related to health care transformation and BCNC’s initiatives.
  • Publish high impact content focused on improving accessibility, quality and affordability.

• Innovation
  • Payment model design
  • Identify market trends that should influence key investments (new technologies, best practices).
  • Evaluation of investment/partnership opportunities

What You'll Bring (Hiring Requirements)

• MD or DO from an accredited medical school and completion of residency training program
• 5+ years of experience in related field
• Current North Carolina medical license or willing to apply/obtain by start date
• Board certification in ABMS/AOA recognized clinical specialty

The Following Specialties are Preferred

• Pain Management
• Orthopedic
• Family Practice

Salary Range