Medical Director

Job not on LinkedIn

🔥 14 minutes ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $214.1k - $297.9k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

👻 Ghost score 17%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• Provide leadership, direction and daily support for the assigned region of New Jersey and assigned providers. • Support utilization management, care management, disease management, quality management, pharmacy management, post-service reviews, provider education, provider relations issues and clinical transformation. • Maintain a personal caseload of daily medical management activities and contribute to operational effectiveness of the medical management program. • Support all lines of business, including Commercial and Government Programs. • Collaborate with value-based teams, Behavioral Health, Pharmacy, accounts and cross-functional regional teams; support sales teams as assigned. • Guide, support and consult with nurse reviewers on pre-authorization, concurrent and retrospective reviews, post-service reviews, pre-determinations and decisions. • Consult with and support case management to determine the best course for members, assist with PG and address issues. • Develop and maintain collaborative relationships with providers through on-site or virtual performance reviews and coaching activities. • Provide input into provider credentialing, profiling and communication initiatives. • Analyze case management and utilization data, identify issues and escalate as necessary to senior management. • Interpret utilization, cost and quality reports and develop steps to address performance variances. • Collaborate on monthly reporting documentation for the assigned region. • Assess network capabilities by region and collaborate on network gaps with network management, contracting and value-based teams. • Create or participate in internal and external educational activities. • Participate in assigned committee activities and serve as backup chair for committees. • Assist with coverage across functional Medical Director teams and participate in calls for all areas. • Support medical policy development, review medical and pharmacy policies and provide utilization feedback. • Work with legal and mandate teams to support compliance with the New Jersey Department of Banking and Insurance. • Perform medical reviews for the Clinical Inquiries Team and support the special investigations unit as needed. • Support development and implementation of reimbursement policies.

🎯 Requirements

• Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards. • Broad clinical knowledge and understanding of current health care issues and climate. • Knowledge of health insurance payer business including business operations. • Board Certification in an American Board of Medicine recognized specialty. • Current unrestricted MD or DO license to practice medicine. • 5-7 years Clinical Experience. • Experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management. • Proficiency working with Tableau or similar software. • Proficiency working with a Windows based environment including MS Office products. • Ability to review studies, understand evidence based medicine and support medical policy development. • Ability to chair committees with internal and external stakeholders. • Active Unrestricted MD or DO License Required; NJ License Required. • No CMS Sanctions or sanctions by other regulatory agencies or boards. • Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties. • Ability to function and work in a matrix environment, including working on and at times leading cross-functional teams. • Ability to identify conflict, determine its causes and negotiate mutually agreeable solutions. • Access to a car and ability to travel for meetings with physicians, hospitals and ancillary providers as required.

🏖️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement