Medical Director, Utilization Management at BlueCross BlueShield of Vermont

Berlin, Vermont, United States -

Full Time

Start Date

Immediate

Expiry Date

02 Jul, 26

Salary

300000.0

Posted On

03 Apr, 26

Experience

10 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization management, Medical necessity determination, Prior authorization, Appeals, Clinical leadership, Medical policy, Regulatory compliance, Quality improvement, Case management, Provider relations, Payment integrity, Healthcare cost management, Clinical criteria systems, Staff training, Managed care, Physician review

Industry

Insurance

Description

Blue Cross and Blue Shield of Vermont is looking for a Medical Director, Utilization Management to lead our UM team. Our company culture is built on an unwavering focus on the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. We offer a balanced and flexible workplace, an onsite gym, fitness and wellness programs, a competitive salary and full benefits package including medical and dental insurance, vision, 401K, paid time off and holidays, tuition reimbursement and student loan repayment, dependent caregiver benefits, and resources to support your ongoing personal and professional growth and development. COMPENSATION: The base salary range for this position is $240K-300K .Additional compensation opportunities and incentives will be detailed during the interview process. Please note that the range listed above is our good faith estimate of the hiring range for this role. If you are hired at Blue Cross and Blue Shield of Vermont, your final base salary compensation will be determined based on factors such as skills, competencies, education, experience, and internal equity across the current team. We also offer a robust benefits package with significant value (see below). LOCATION: Blue Cross has transitioned to a hybrid workplace. It is expected that the qualified candidate will be in the Berlin VT office on Tuesdays and Wednesdays. Medical Director, Utilization Management Responsibilities: * Serve as the physician leader for medical management, with primary accountability for utilization management (UM) decision making, including physician-level medical necessity determinations, prior authorization reviews, appeals, and provider-to provider discussions. * Oversee the work of the Director, UM and works closely with the UM team and other Medical Directors to ensure reviews are completed within required state and NCQA timeframes. * Serve as the final clinical authority for medical necessity determinations in accordance with medical policy and regulatory requirements. * Contribute to the continuous improvement of UM operations to enhance efficiency, consistency, and effectiveness, and partners with the Quality, Case Management, Provider Relations, and Payment Integrity teams to support coordinated care, improved member outcomes, and using lower cost, effective alternatives for responsible healthcare cost management. * Play a key role in developing, training, and supporting UM staff, and actively uses UM technology platforms and clinical criteria systems to support high-quality, timely decision making. Medical Director, Utilization Management Qualifications: * Unrestricted Vermont medical license compliant with leadership and infrastructure requirements of Vermont State Law, URAC, and NCQA. * M.D. or D.O. degree. * Board certification in an American Board of Medical Specialties (ABMS) approved specialty. * Seven to ten (7-10) years of clinical practice experience combined with three (3) years of clinical management experience serving as a physician reviewer for UM, prior authorization, and appeals in a health plan or managed care environment. * Prior medical administrative background is highly desirable. * Advanced management degree or equivalent preferred. * Excellent knowledge of local health care delivery systems and existing relationships with local network providers and medical facilities is highly desirable. * Must be able to work a hybrid schedule working a minimum of one to two (1-2) days onsite; with Vermont residency preferred. Medical Director, Utilization Management Benefits: * Health insurance (including vision) * Dental coverage (free to employees) * Wellness Program * 401(k) with employer match + automatic employer contribution * Life Insurance * Disability Insurance * Combined time off (CTO) – 20 days per year + 10 paid holidays * Tuition Reimbursement * Student Loan Repayment * Dependent Caregiver Benefits Diversity, Equity, and Inclusion: Blue Cross VT is committed to creating an inclusive environment where employees respect, appreciate, and value individual differences, both among ourselves and in our communities. We welcome applicants from all backgrounds and experiences to join us in our commitment to the health of Vermonters, outstanding member experiences, and responsible cost management for all the people whose lives we touch. Learn more about our DE&I commitment at http://www.bluecrossvt.org/about/diversity-equity-and-inclusion [http://www.bluecrossvt.org/about/diversity-equity-and-inclusion]. *Complete job description attached to ADP posting

Responsibilities

The Medical Director serves as the physician leader for utilization management, overseeing medical necessity determinations, prior authorization reviews, and appeals. They also contribute to operational improvements and provide clinical leadership to the UM team to ensure high-quality, efficient healthcare delivery.