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Medical Director, MD or DO Required
Blue Cross and Blue Shield of Nebraska. Lead development and implementation of strategies promoting medical management, practice transformation, patient satisfaction, quality improvement, and cost reduction .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates clinical expertise in medical management, utilization review, and quality improvement while effectively leading teams and fostering relationships with providers and stakeholders. Possesses strong capabilities in managing Medicare Advantage programs and ensuring compliance with medical necessity standards.
Highest-signal resume keywords
Doctor Of Medicine (M.D. Or D.O.)Board Certified By An American Board Of Medical SpecialtiesUtilization ReviewManaged Care ExperienceClinical Oversight
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ManagementPrior AuthorizationCase ManagementQuality ImprovementClinical CodingReimbursement ExpertisePopulation Health OutcomesCost ManagementEvidence-Based ReviewsClinical Workflow Analysis
Soft Skills
Team CollaborationRelationship BuildingStakeholder EngagementCommunication SkillsProblem Solving
Certifications & Qualifications
Active Nebraska Clinical LicenseBoard Certification
Industry Keywords
Health Care Delivery SystemMedicare AdvantageClinical PracticeQuality AssurancePatient Satisfaction
About the role
Key responsibilities & impact- Lead development and implementation of strategies promoting medical management, practice transformation, patient satisfaction, quality improvement, and cost reduction
- Enhance relationships with providers, facilities, and internal/external partners
- Act as project manager for assigned medical management programs, including utilization, prior authorization, case management, and Medicare Advantage
- Provide clinical oversight of assigned areas such as utilization review/quality assurance, case management, quality, population health outcomes, and cost management
- Conduct evidence-based, clinically sound, timely, and compliant medical necessity reviews for utilization management appeals
- Support Medical Management staff and external partners with timely and consistent responses to members and providers
- Provide clinical expertise and business direction through clinical and policy team activities
- Perform utilization review, prior authorization, pre-certification, concurrent certification, predetermination, and claim determination reviews
- Provide clinical, coding, and reimbursement expertise
- Conduct peer-to-peer conversations with attending physicians or ordering providers
- Develop physician and staff relationships, identify and disseminate best practices, analyze clinical workflows, and support quality improvement and utilization-reduction interventions
Requirements
What you’ll need- Doctor of Medicine (M.D. or D.O.)
- Seven (7) years of experience in a health care delivery system, such as clinical practice and the health care industry
- Board certified by an American Board of Medical Specialties board
- Active, current, and unrestricted license to practice medicine in a state or territory of the United States
- Postgraduate direct patient care experience
- Active, current, and unrestricted Nebraska clinical license allowing clinical judgment for utilization review determinations
- Three (3) years of direct clinical care in private and/or academic practice
- Based on area of assignment, ability to complete the role in Nebraska
- Equivalent combination of education and experience may be substituted
- Ability to meet department attendance and timeliness requirements
- Ability to work well in a team environment and build and maintain positive relationships
- 2+ years of managed care experience, preferably with a Medicare Advantage population
- Demonstrated ability to create buy-in with internal and external clinician stakeholders to transform clinical care
Benefits
Comp & perks- Opportunities and support to build a meaningful career
- Reasonable accommodations for individuals with disabilities
- Diversity, experience, perspective, and background valued in the workplace