Medical Director Care Management

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Company: Florida Blue
Location: United States

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**Position can be based from remote location**

  • Perform all types of utilization management (UM) reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
  • Discuss cases with physician providers (Peer to Peer)
  • Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
  • Collaborate with Case Managers to provide support and guidance on cases needing physician assistance
  • Meet any established metrics (compliance and accreditation) related to UM review efficiency, timeliness, and quality of review
  • Participate in ongoing Inter-rater reliability (IRR) audits and any other health plan audits as necessary
  • As necessary, assist nurses and other staff in understanding the principles behind appropriate utilization review and interpretation and application of benefits and policies
  • Participate in the development and review of Medical and Pharmacy policies as assigned
  • Support the organization as a subject matter expert
  • Perform as lead Medical Director consultant for one sub-category of utilization management, such as commercial or Medicare medical policy
  • Perform other duties as assigned and needed by the organization


Job Requirements:

  • Current unrestricted Florida medical license as a Doctor of Medicine or Doctor of Osteopathic Medicine
  • Board Certified or equivalent
  • 5+ years of clinical experience
  • Experience working in a dynamic, fast-paced environment
  • Experience working both independently and in a team environment
  • Exceptional verbal and written communication


Preferred:

  • Physician reviewer or utilization management experience
  • Primary Care Specialty physician experience

We are an Equal Opportunity Employer/Protected Veteran/Disabled.