Job Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Medical Director provides medical guidance and support to the full spectrum of Capital’s Clinical Utilization Management activities and programs. Supports appropriate Utilization Management goals and objectives.

Provides professional leadership and direction to the functions within the Utilization Management Department.

*This is an independently contracted role, approximately 15-20 hours/week, at least one weekend every other month, as well as rotating Holiday coverage.

*To be considered, you must have a current license to practice in the state of PA

Responsibilities and Qualifications

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies, render coverage determinations
• Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements
• Engage with requesting providers as needed in peer-to-peer discussions
• Be knowledgeable in interpreting existing benefit language and policies in the process of clinical coverage reviews
• Communicate and collaborate with network and non-network providers in pursuit of accurate and timely benefit determinations for plan participants while educating providers on benefit plans and medical policy
• Makes coverage determinations in instances where requested services do not meet medical necessity criteria or where benefit exclusions require medical evaluation.
• Makes medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
• Provides Medical Director leadership to Vendor relationships as directed by the Managing Medical Director.
• Supports organizational accreditation efforts and regulatory review processes: Prior- Authorization, Concurrent Review, Medical Claims Review, Case Management, Disease Management, Pharmacy Management, and Health Education programs.
• Performs other related duties and assignments as directed.

Knowledge:

• Knowledge of current and emerging medical treatment modalities.
• Familiarity with National Committee for Quality/URAC standards.

Skills:

• Demonstrated public speaking and written communication skills.

Experience:

• A minimum of five years clinical experience, post residency, including both inpatient and outpatient care.
• At least three years’ experience in managed care, utilization review, and/or quality management.

Education, Certification, and Licenses:

• Minimum requirements include an MD or DO Degree, as well as appropriate Board Certification.
• Current unrestricted licensure in Pennsylvania as an MD or DO.
• Currently covered by, or eligible to be covered by, medical liability insurance.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.