Lead Medical Director

• Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute
• Annual incentive bonus plan based on company achievement of goals
• Time away from work including paid holidays, paid time off and volunteer time off
• Professional development courses, mentorship opportunities, and tuition reimbursement program
• Paid parental leave and adoption leave with adoption financial assistance
• Employee discount program

• Provide computer-based clinical reviews of moderately complex to complex clinical scenarios to include a review of all submitted clinical records, external telephonic conversations with the providing physician in the form of Peer-to-Peers, and close collaboration with the nursing team.
• Able to review at overall data to then inform strategy around continuous improvement of healthcare delivery as well as individual decision making.
• Demonstrate critical thinking skills in decision making by applying the correct guidelines in the greater context of delivering the best quality of care to members while achieving cost efficiency.
• Display ability to have active listening skills, ask key questions, and demonstrate compassion towards all parties when making decisions that may not have universal agreement, particularly around utilization review activities.
• Review individual member experiences to identify where care gaps exist and identify resources (external and internal), participate in group rounds to discuss complex cases from a holistic perspective, and assure that evidence-based guidelines are driving care decisions.
• Possess a broad base of medical knowledge but also a willingness to learn and expand clinical acumen to provide decision making across all medical specialties as well as having a collaborative approach to seek additional input where needed to arrive at the best decision.
• Improves the quality and efficiency of care in the network and integrates providers into Blue KC clinical initiatives by providing direction to physicians and other providers, Provides utilization management for medical, surgical and pharmacy activity.
• Participates in medical appeals activity. Reviews all appealed cases related to medical necessity/investigational issues in the context of potential medical policy updates.
• Serves as expert/resource on appeals related to utilization management issues.
• Provides medical leadership and physician advice to the quality management area with respect to quality improvement studies, quality improvement committees. Performs peer reviews on quality complaints, sentinel events, and quality-of-care referrals.
• Serves as physician advisor for other areas within the company, including but not limited to Sales and Marketing, Special investigations Unit (fraud and abuse), Legal, Product Development, Compliance and Provider Services.
• Provides medical leadership and advice for conformance with standards and guidelines for NCQA, URAC, state and federal regulators, and other accrediting bodies.
• Acts as liaison for communication with physicians, hospitals, and other providers in the community.
• Reviews customer service and claims inquiries.

Minimum Qualifications

• M.D. or D.O. degree from an accredited medical school required.
• 5 + years or experience in direct clinical patient care post-residency or fellowship training.
• Board certification in an approved American Board of Medical Specialties (ABMS) specialty with continued certification throughout employment required.
• Current unrestricted medical license to practice medicine in the states of Missouri and Kansas or willingness to obtain upon hire required.
• Experience with quality improvement and utilization improvement work/projects
• Excellent verbal and written communication skills
• No current sanction from Federal or State Governmental organizations; ability to pass credentialing requirements.
• Ability to utilize technology efficiently in various platforms including all Microsoft products, various EMR's, and other platforms.
• 2 years experience in performing utilization management activities, preferably a managed care setting but other UM activities considered.
• The curiosity to continuously learn, the desire to innovate, the ability to demonstrate calm in the face of change, and the courage to act with integrity.
• Experience with NCQA and URAC accreditation preparation and review.
• Experience managing others in a hospital department or industry setting.

Preferred Qualifications

• Advanced degree such as an MBA, MHA, or MPH or other recognized certifications / training specific to administrative medicine.
• Experience as chairperson of a hospital committee or department or practice If not payer experience.
• Experience with national guidelines (e.g. MCG, Inter Qual, CMS)
• Internal Medicine, Family Practice, Geriatrics, Hospitalist, Emergency Medicine clinical specialization.
• Knowledge with 3 years of the managed care industry including Medicare Advantage, and/or Managed Commercial products, Integrated Delivery Systems, health insurance, other healthcare providers, clinical group practice management.
• Experience in medical oversight for a Medicare Advantage product.
• Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation).

Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability.