Medical Director

NJM Insurance Group

Medical Director providing leadership in healthcare at Horizon Blue Cross Blue Shield. Managing clinical operations and collaborating with healthcare providers in New Jersey.

Posted 5/13/2026full-timeRemote • New Jersey • 🇺🇸 United StatesLead💰 $214,100 - $297,885 per yearWebsite

Tech Stack

Tools & technologies

Tableau

About the role

Key responsibilities & impact

Support all lines of business which includes Commercial and Government Programs.
Collaborate with value-based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable.
Supports sales teams as assigned by region.
Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable.
Consult with/support case management to determine best course for members, assist with PG and address issues.
Develops and maintains effective collaborative relationships with providers in assigned geographic areas.
This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers.
May provide input into provider credentialing, profiling and communication initiatives.
Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management.
Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix.
Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region.
Assists with assessment of network capabilities by region and collaborates with network management, contracting and value-based teams in addressing network gaps.
Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas.
Participates in Committee activities as assigned.
Assist with coverage across functional MD teams, as needed, including participation in calls for all areas.
Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team.
Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI).

Requirements

What you’ll need

Requires Board Certification in an American Board of Medicine recognized specialty
Requires current unrestricted MD or DO license to practice medicine.
Requires 5-7 years Clinical Experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management.
Proficiency working with Tableau or similar software required.
Proficiency also required working with a Windows based environment including MS Office products.
Continuous Improvement Experience Preferred.
Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards.
Requires broad clinical knowledge and understanding of current health care issues and climate
Requires some knowledge of health insurance payer business including business operations.
Specific to Medical Policy: Ability to review studies, understand evidence-based medicine and support medical policy development.
Ability to chair committees with internal and external stakeholders.

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

data analysisutilization managementcase managementquality managementevidence-based medicinemedical policy developmentclinical experiencerecommendation developmentperformance matrix analysiscredentialing

Soft Skills

collaborationcoachingcommunicationrelationship buildingproblem solvingleadershipstakeholder engagementcommittee chairingconsultationcross-functional teamwork

Certifications

Board Certification in MedicineMD licenseDO license