This position provides physician support and guidance for the medical management and quality management programs of the Government Business division of BCBST. The incumbent performs physician review activities for pre-certification, concurrent review, appeals, case management and disease management; and manages the daily workload of physician reviews. He or she acts as an internal medical consultant to various VSHP departments and committees to support the development, implementation and monitoring of medical management activities of BlueCare, TennCare
, Cover Tennessee products and other managed government programs. The Medical Director interfaces with network physicians and other practitioners as necessary to support medical management, network management and clinical quality improvement activities of VSHP.
Job Duties & Responsibilities
Perform physician review for Utilization Management, Case Management and Appeals, includes discussing medical necessity determinations with individual physicians as necessary.
Manage daily volume of cases requiring physician review/consultation to ensure turnaround time complies with state and national regulatory/accreditation standards and promotes good customer service with practitioners and other providers.
Serve as a consultant for medical policy and benefit interpretation.
Interface with participating physicians, facilities and other providers as necessary.
Participate in individual regional management team activities as necessary.
Support committees, task forces and workgroups, as necessary, which are responsible for or integrate with the medical management program.
MD or DO with an active, unrestricted license to practice medicine in Tennessee
Board certification in a specialty recognized by the American Board of Medical Specialties or the American Osteopathic Association is preferred. It is required for physicians who perform physician review of Appeals.
Minimum of 5 years clinical experience and 3 years of healthcare administration, including Utilization Management experience.
Clinical experience as an Internist or a Family Practitioner is preferred.
Excellent interpersonal, organizational, negotiating, teaching and analytical skills are essential.
Ability to work effectively within a team environment.
Working knowledge of Facets preferred.
Knowledge of personal computers and software programs, especially Microsoft Office and Outlook required.
BlueCross BlueShield of Tennessee (BCBST) is the oldest and largest not-for-profit managed care provider in the state of Tennessee....