Medical Director

NJM Insurance Group

Medical Director providing clinical leadership and operational support at Horizon Blue Cross Blue Shield. Responsible for ensuring quality management and collaboration across healthcare providers.

Posted 5/15/2026full-timeHopewell • 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)
Backup chair for committees with internal and external stakeholders
Performs medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed
Support development and implementation of reimbursement policies
Assist with coverage across functional MD teams as needed including participation in calls for all areas

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
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

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 developmentreimbursement policiesclinical experiencecontinuous improvementcredentialing

Soft Skills

collaborationcoachingcommunicationrelationship buildingproblem solvingleadershipconsultationorganizational skillsstakeholder engagementcommittee chairing

Certifications

Board CertificationMD licenseDO licenseNJ License