The position is accountable for providing leadership, direction, and daily support for the assigned Community team (Community Based Care Management Model/CBCM) scope of activities including support for Utilization Management, Case Management, Chronic Care Management, Preventive Health Management, Quality Management, Pharmacy Management, and network and hospital relations within the Community. The position is accountable for performance within the community, in support of Enterprise goals and objectives.
Provides daily leadership and direction, in a matrix management environment, for the Community Based Care Management Model team. This includes Medical Director Support for all aspects of daily medical management activities, as well as providing the leadership for CBCM administrative and clinical meetings.
Ensures integration of clinical functions to ensure improved member specific and population based outcomes.
Interprets and analyzes available utilization, cost and quality reports, and develops actionable steps to address variances to target performance metrics. Documents a monthly report addressing performance, identified issues, and activities for the assigned region.
Responsible for assessing network capabilities within region, and collaborates with network management and contracting in addressing network gaps.
Develops and maintains effective collaborative relationships with providers in assigned geographic areas. This includes on site review of performance and coaching activities with physicians, hospitals and ancillary providers.
Functions as a resource for issue resolution within Community.
Functions as a resource to the team with regard to care management issues, complex case management, and quality of care issues, and facilitates resolution.
Guides staff in the interpretation of Medical Policy, and provides Medical Director Support for Appeals activity.
Participates in Committee activities as required.
Other duties as required by management.
Minimum five (5) years clinical experience required, with three (3) or more years of medical management experience preferred.
Additional licensing, certifications, registrations:
Requires current unrestricted NJ MD or DO license to practice medicine.
Requires current Board Certification in an (American Board of Medical Specialties) ABMS recognized specialty.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.
Knowledge in the principles of Utilization Management, Case Management, Quality Management, and accreditation and regulatory standards.
Requires broad clinical knowledge and understanding of current health care issues.
Requires knowledge of health insurance payer business, including operations.
Skills and Abilities:
Planning and Organizing: Leveraging resources; staying focused; effectively prioritizing.
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.
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.
Business Acumen: Understanding data to identify key issues, and developing strategies and plans .
Executive Disposition: Advocates for organization; manages stress; exhibits flexibility and adaptability.
Conflict resolution: ability to identify conflict, determine its causes and negotiate mutually agreeable solutions.
Coaching: Able to identify coaching opportunities, and use these opportunities appropriately and timely to support goals.
Team building: Encourages the full participation of all team members; makes maximum use of diverse talents of all team members; and builds strong team to meet performance goals.
Initiative: Effectively initiates solutions; continuously finds new and better ways of performing job; is alert to new opportunities, techniques and approaches.
Effective verbal and written communication skills the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.
Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities and deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
Proven analytical, research and problem solving skills.
Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to change as appropriate.
Exhibits an energetic, inquisitive, positive approach to problem solving.
Experience in successfully leading cross-functional teams to achieve improvements.
Travel (If Applicable):
Position requires access to an automobile, and the ability to travel for meetings with physicians, hospitals and ancillary providers as required.
Horizon Blue Cross Blue Shield of New Jersey - 17 months ago
Medical Director I - CBCM
Horizon Blue Cross Blue Shield of New Jersey
New York, NY
Horizon Blue Cross Blue Shield of New Jersey
- 30+ days ago