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Job Description

The Medical Director brings a unique set of knowledge and skills to the business of Blue Cross North Carolina and frequently serves as an interface between the company and physicians, providers, employer and community groups, and members as needed. Utilizes clinical knowledge and experience to support value-based strategies, clinical operations and our organizational pursuit of high quality and cost-effective care for members.

Hiring range for this position: $200,000 - $212,000

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

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

$146,500.00 - $278,200.00

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.

Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please notify HR at HR.Staffing@bcbsnc.com .

For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two:

Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming