Job Description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

Promote and support the BlueCross and BlueShield of Louisiana (BCBSLA) Mission Statement. Reviews treatment procedures and services to ensure that they are within established guidelines or supported by generally accepted medical evidence when formal guidelines do not exist. To provide direction to operations as applicable, including utilization activities including but not limited to Utilization Management, Case Management and Disease Management, Population Health and Wellness. Facilitates all physician and provider committees as needed. Provides advice on external contractual benefit issues.

NATURE AND SCOPE

• This role does not manage people
• This role reports to this job: SENIOR MEDICAL DIRECTOR (MGR)
• Necessary Contacts: department Managers, Authorization, Utilization Management, Case Management, Disease Management, Compliance personnel, and other employees as indicated, Licensed Doctors of Medicine (Physicians), Hospitals, and other healthcare providers, Parish and state medical agencies and societies as needed, Accreditation and governmental entities’ personnel as needed.

QUALIFICATIONS

Education

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) required
• Must be qualified to render a clinical opinion about the medical condition, procedures and treatment under review.

Work Experience

• 7 years of clinical practice experience is required
• 3 years of post graduate experience with direct patient care required; prefer 5 years of experience.
• Administrative experience in a health plan and/or a working knowledge of the insurance industry preferred
• Prior detailed experience in either utilization, case or disease management in a hospital or health plan setting preferred, along with a positive history of providing consultative efforts concerning medical and legal issues are preferred
• Experience with external accreditation bodies; JCAHO, URAC, or NCQA preferred
• Medicare Advantage experience is preferred

Skills and Abilities

• Excellent communication, presentation, interpersonal and human relation skills are required.
• Microsoft Office software Word, Excel, Outlook, PowerPoint proficiency required.
• The position requires availability for travel and working extended hours.

Licenses and Certifications

• Current, license to practice medicine in Louisiana of the type and scope that permits application of clinical judgement in consideration of an individual member’s clinical needs to render a utilization review determination
• License must be unrestricted; or if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer
• Must have the ability to obtain a medical licensure for the state of Louisiana required
• Board certification in a specialty recognized by ABMS required
• Behavioral Health: Board Certification in P sychiatry is required

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Fulfills medical director duties as appropriate which include but are not limited to: peer reviews, case reviews, completion of inter-rater reliability case reviews annually, active participation in training activities, provision of documentation to support compliance with annual licensure requirements, claims review to determine proper resolution, maintaining a working knowledge of company policies and procedures.
• Interacts with physician and non-physician network providers on programs which may include: Performance Profiling, Disease State Management, Wellness, Medical Policy and claims related issues.
• Reviews, provides medical expertise and reports on activities related to utilization, case, and disease management, Authorizations, Compliance, Network Administration, Southern National Life (SNL), Legal and other departments requiring guidance.
• Participates in and supports internal operations such as quality assurance efforts, the BCBSLA Quality Improvement Plan, accreditation/URAC related activities and requirements, medical policy, network operations, diversity initiatives and similar initiatives.
• Participates in and/or acts as a voting member on committees which may include but is not limited to: Pharmacy & Therapeutics, Credentialing and Second Level Administrative Appeals as directed by the Senior Medical Director.
• Completes required training activities in a timely manner.
• Complies with Licensure & Board Certification requirements. Reports adverse changes in licensure, Board Certification to the Senior Medical Director within one business day of notification.
• Complies with all laws and regulations associated with duties and responsibilities.
• Reviews requests for services for prior authorization, concurrent stay and retro review based on commercial criteria, Medical Policies application of member contract benefits, or if formal guidelines do not exist, makes determinations of medical necessity supported by generally accepted medical evidence.
• - Consults with initial clinical reviewers as needed.
• - In cases of non-certification determinations, conducts peer clinical reviews with attending physicians or orders providers within one business day of a request while in compliance with accreditation standards.
• - When the clinical peer reviewer making the initial determination is not available, does peer to peer in his/her place.
• - If peer to peer conversation does not result in certification, notifies provider of consumer's right to initial and appeal and the related procedure.
• Performs medical or administrative appeals as needed based on medical policy, benefit language or standard of care.

Additional Accountabilities and Essential Functions
The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.