Medical Director – Utilization Management
Capital Blue Cross
part-time
Posted on:
Location Type: Remote
Location: Pennsylvania • United States
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Salary
💰 $100 - $150 per hour
Job Level
About the role
- Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies.
- 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.
- Make medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review.
- Support organizational accreditation efforts and regulatory review processes.
Requirements
- 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.
- Current unrestricted licensure in Pennsylvania as an MD or DO.
- Appropriate Board Certification.
- Knowledge of current and emerging medical treatment modalities.
- Familiarity with National Committee for Quality/URAC standards.
- Currently covered by, or eligible to be covered by, medical liability insurance.
Benefits
- Health insurance
- Flexible work arrangements
- Professional development opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewmedical necessity determinationutilization reviewquality managementcoverage reviewdocumentationaccreditationpeer-to-peer discussionsinpatient careoutpatient care
Certifications
MDDOBoard Certificationmedical liability insurance