Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, disease management, quality management, pharmacy management, post service reviews, provider education, support for provider relations issues, and clinical transformation. The Medical Director is accountable for a personal caseload of daily medical management activities and contributing to operational effectiveness of the medical management program.Responsibilities:
Medical Policy and HPIRIT only:
Functional Competencies:
Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards.
Requires broad clinical knowledge and understanding of current health care issues and climate.
Requires some knowledge of health insurance payer business including business operations.
Education/Experience:
Requires Board Certification in an American Board of Medicine recognized specialty Requires current unrestricted MD or DO license to practice medicine.
Requires 5-7 years Clinical Experience Experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management.
Proficiency working with Tableau or similar software required.
Proficiency also required working with a Windows based environment including MS Office products.
Continuous Improvement Experience Preferred.
Specific to Medical Policy:
Ability to review studies, understand evidence based medicine and support medical policy development.
Ability to chair committees with internal and external stakeholders.
Additional licensing, certifications, registrations:
Active Unrestricted MD or DO License Required; NJ License Required, No CMS Sanctions or sanctions by other regulatory agencies or boards.
Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.
Knowledge, Skills and Abilities:
Business Acumen: Identify key issues and opportunities, developing strategies and plans and have resolute decision making.
Planning and Organizing: Leveraging resources, staying focused and effectively prioritizing key objectives.
Building Strategic Working Relationships: Proactively tries to build effective working relationships; facilitates agreement; clarifies current situation; involving appropriate individuals within team and broader organization to achieve desired results.
Executive Presence: Advocates for the organization, inspiring confidence among peers regarding reliability and capability, inspiring senior leadership expectations on potential for outstanding outcomes and achievements.
Meeting Leadership: Ensures a meeting serves its business objectives; facilitating agreement; develops others' and own ideas; closes discussions with clear summaries.
Negotiation: Effectively exploring alternatives and positions to reach outcomes that gain the support and acceptance of all parties.
Matrix Environment: Ability to function and work in a matrix environment which includes working on and at time leading cross functional teams.
Conflict resolution: ability to identify conflict, determine its causes and negotiate mutually agreeable solutions.
Travel % (If Applicable):
The position requires access to a car and the ability to travel for meetings with physicians, hospitals and ancillary providers as required.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Salary Range:
$211,000 - $293,475This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.