Medical Director

• Lead, supervise, and support provider teams, ensuring clinical quality and regulatory compliance.
• Manage hiring, training, coaching, and performance evaluation for direct reports.
• Strategically deploy clinical resources using data-driven KPIs to achieve market and organizational goals.
• Develop and nurture partnerships with local clinical communities, health plans, and other key stakeholders.
• Champion our value-based, patient-centered care model for the frailest and most vulnerable populations.
• Deliver clinical oversight for patient care, including annual wellness visits, urgent care, care transitions, and continuity care.
• Participate in care team huddles, providing expert clinical guidance to drive better outcomes and overall performance improvements.
• Ensure compliance with all medical and operational policies, protocols, and guidelines.
• Support direct patient care and on-call activities as needed.

Market Medical Director

• Supports clinicians to ensure timely and consistent responses to members and providers
• Provides guidance for clinical operational aspects of a program
• Serves as a resource and consultant to other areas of the company
• May be required to represent the company to external entities and/or serve on internal and/or external committees
• May chair company committees
• Interprets medical policies and clinical guidelines
• May develop and propose new medical policies based on changes in healthcare
• Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes
• Identifies and develops opportunities for innovation to increase effectiveness and quality

Medical Director – Medicare Fee for Service

• Determines the medical necessity of requests using clinical criteria
• Performs physician-level case review of surgical utilization requests
• Conducts peer-to-peer consultation with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, procedures, imaging and appropriate sites of service
• Provides education regarding applicable clinical criteria and discusses clinically appropriate interventional and non-interventional options
• Performs first level provider appeals for coverage decisions
• Provides support and education to internal clinical and non-clinical staff regarding the principles associated with appropriate diagnoses, treatments, and management of conditions and surgical procedures
• Participates in physician team meetings
• Participates in groups that develop, revise and enhance clinical appropriateness guidelines

Medical Director – Surgery

• Bring knowledge and skills to the business of Blue Cross North Carolina
• Support value-based strategies and clinical operations
• Develop and drive strategy for varied Health Care initiatives
• Partner with internal and external clients to support agreements
• Evaluate and manage vendors to align with strategic direction
• Gather and analyze data for health outcomes improvement
• Represent BCNC through presentations and leadership

Associate Medical Director

• The Director of Clinical Services (DCS) is accountable for clinical and operational excellence within a defined book of business in an Envision Physician Services operating unit.
• This position drives improvements in patient care processes and outcomes by partnering with local practice medical leadership and front-line clinicians.
• Within a defined book of business, the DCS balances the needs and opportunities of a client with internal EMG relationships throughout their portfolio.
• The DCS identifies areas of opportunity within their book of business and works collaboratively with operating unit leadership team to provide partnership to medical directors and clients towards performance enhancement and goal achievement.
• The DCS drives implementation of clinical quality, service line clinical operations, corporate initiatives.

Director of Clinical Services

• Provide leadership and day-to-day physician oversight for utilization management team, including the management of high-risk cases and medical necessity decisions
• Provide comprehensive behavioral health care management to facilitate delivery of appropriate quality care and improve program/operational efficiency involving clinical issues
• Participate in the appeals process, including the investigation of adverse events and quality of care concerns
• Provide psychiatric leadership to an interdisciplinary utilization management team, including medical/clinical oversight, consultation and training
• Provide day-to-day physician oversight including management of high-risk cases throughout treatment/levels of care and medical necessity decisions
• Assist with the development, implementation, monitoring and evaluation of the utilization management program and action plan, ensuring quality and appropriateness of care
• Assist with the development, implementation and interpretation of medical policy including medical necessity criteria, clinical practice guidelines and new technology assessments
• Participate in the development, implementation, and evaluation of clinical/medical programs
• Confer with behavioral health practitioners regarding the care of patients with severe, complex and/or treatment resistant illnesses
• Identify and address quality of care concerns with providers involved in a member's care
• Provide psychiatric leadership for NCQA-compliant clinical quality improvement activities in collaboration with clinical and quality improvement staff
• Participate in the triage and referral for care management
• Provide weekend coverage every 6-7 weeks.
• Perform other duties as deemed necessary.

Behavioral Health Medical Director

• Medical Director responsible for the administration of physical and/or behavioral health medical services.
• Ensure the appropriate and most cost-effective medical care is received.
• May be responsible for developing and implementing programs to improve quality, cost, and outcomes.
• Provides clinical consultation and serves as clinical/strategic advisor.
• Identifies cost of care opportunities.
• Serves as a resource to staff including Medical Director Associates.
• Conducts peer-to-peer clinical reviews and may represent the company to external entities and/or serve on committees.

• ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request
• ensure Utilization Management, including prior authorization and pre certification as well as concurrent review
• focus on inpatient or outpatient, acute and post acute as well as peer to peer calls and first level appeals

Medical Director – Kentucky Medicaid

• Ensure timely and consistent responses to members and providers related to precertification, concurrent review, and appeal request.
• Primarily responsible for Utilization Management, including prior authorization and precertification as well as concurrent review.
• Cases could focus on inpatient or outpatient, acute and post-acute as well as peer to peer calls and first level appeals.
• Participate in a rotating on call schedule to provide weekend and holiday coverage.

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