Medical Director

• Develops ongoing professional relationships with key decision makers in organized health systems to ensure access to medical and scientific information on the full oncology product portfolio and areas of therapeutic interest
• Develops strategic account plans in partnership with the Integrated Account Management (IAM) Account Executive teams and executes medical activities in alignment with agreed plan
• Serves as the primary resource for market dynamics within the territory to understand decision makers’ evolving information needs to feed into the ongoing value-proposition development process for oncology product and non-product offerings
• Effectively communicates and coordinates with Regional Medical Scientific Director regarding medical and scientific support needs in key health systems accounts
• Serves as a resource for the HSO MAD Team Lead, HSO Executive Director Medical Affairs, and other members of Country Medical Affairs on other relevant strategic planning
• Attends and supports scientific and medical meetings and prepares post-meeting deliverables

Health Systems Oncology Medical Affairs Director

• 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

• Administration of physical and/or behavioral health medical services
• Ensure appropriate and cost-effective medical care
• Develop and implement programs to improve quality, cost, and outcomes
• Provide clinical consultation and serve as advisory to enhance clinical operations
• Identify cost of care opportunities
• Serve as a resource to staff including Medical Director Associates
• Represent the company to external entities

Medical Director – Family or Emergency Medicine

• Plan and execute Medical strategy and engagement in assigned territory
• Maintain knowledge of relevant TA/disease states and Pfizer medicines
• Serve as a resource for Medical Information and customer insights
• Understand priorities of Pfizer Medical Affairs to contribute to strategy development
• Communicate and collaborate with headquarters and other colleagues
• Deliver approved medical content about Pfizer medicines to HCPs
• Provide accurate information in response to unsolicited medical requests
• Collaborate with Oncology Research & Development for clinical trials
• Cultivate research and therapeutic area expertise
• Mentor and participate in special projects as needed

Oncology Field Medical Director

• Conduct electronic review of escalated cases against medical policy criteria
• Complete initial determination of cases, review of appeals and grievances, and other reviews as assigned
• Compose clear and concise rationales for member and provider determination notifications
• Participate as a member of the CMDM multidisciplinary team
• Advise multidisciplinary team on cases that require physician expertise
• Actively manage projects and/or participate on project teams that require a physician subject matter expert

• Assist the Chief Medical Officer to direct and coordinate the medical management, quality improvement and credentialing functions for the business unit
• Provides medical leadership of all for utilization management, cost containment, and medical quality improvement activities
• Performs medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services, ensuring timely and quality decision making
• Supports effective implementation of performance improvement initiatives for capitated providers
• Assists Chief Medical Officer in planning and establishing goals and policies to improve quality and cost-effectiveness of care and service for members
• Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, corporate, and accreditation requirements
• Assists the Chief Medical Officer in the functioning of the physician committees including committee structure, processes, and membership
• Conduct regular rounds to assess and coordinate care for high-risk patients, collaborating with care management teams to optimize outcomes
• Collaborates effectively with clinical teams, network providers, appeals team, medical and pharmacy consultants for reviewing complex cases and medical necessity appeals
• Participates in provider network development and new market expansion as appropriate
• Assists in the development and implementation of physician education with respect to clinical issues and policies
• Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components
• Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care
• Interfaces with physicians and other providers in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality
• Reviews claims involving complex, controversial, or unusual or new services in order to determine medical necessity and appropriate payment
• Develops alliances with the provider community through the development and implementation of the medical management programs
• As needed, may represent the business unit before various publics both locally and nationally on medical philosophy, policies, and related issues
• Represents the business unit at appropriate state committees and other ad hoc committees
• May be required to work weekends and holidays in support of business operations, as needed

• 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.

Medical Director – Medicaid

• Provides strategic direction, professional oversight, and leadership throughout the precert process and other clinical operations.
• Collaborates with executive leadership to develop and implement strategies that align with healthcare objectives, improve processes, drive innovation, and positively impact members and providers.
• Leverages medical and operational expertise to develop and align the company's goals with clinical strategies and regulatory requirements.
• Collaborates with cross-functional leaders to shape and drive the clinical operations strategy and initiatives, ensuring optimal quality and efficiency.
• Establishes clinical standards and oversees clinical governance structures to ensure patient safety and the provision of quality care.
• Leads the development of clinical processes and programs, such as clinical protocols, guidelines, treatment pathways, and training curricula.
• Manages operations of the Medicare Precertification MD Team, in alignment with governing policies and procedures.
• Leads teams through Medicare audits and on-going audit readiness.
• Stays updated on relevant scientific evidence, industry standards, and regulatory changes to ensure organizational compliance and relevance.
• Develops and maintains relationships with key stakeholders, such as government agencies, providers, and professional organizations.
• Develops and continuously monitors key metrics to assess the performance of strategic initiatives and processes, making adjustments as needed.
• Provides mentorship, professional development opportunities, and support to physicians, promoting their growth and ensuring a cohesive and skilled medical team.
• Collaborates with legal and compliance teams to ensure developed clinical processes and solutions comply with all applicable regulatory requirements.

Senior Medical Director – Precertification

• Provide medical oversight, expertise and leadership to ensure the delivery of cost effective, quality healthcare services to health plan members.
• Serves as clinical advisor to and educator of medical management staff.
• Provide leadership and expertise in the development, implementation and interpretation of medical review and quality related policies and guidelines.
• Provide oversight and direction for staff and provider training and education.
• Promote positive relations with the local medical community.
• Review case management data, identifies trends and gaps in care and recommends corrective actions.
• Review all quality of care issues and oversees the development and implementation of processes for improvement.
• Monitor performance indicators to ensure the delivery of cost-effective care within quality standards.
• Monitor member and provider satisfaction and recommends and implements changes to improve satisfaction levels.
• Work collaboratively to develop corporate clinical care standards and medical practice policies.
• Provide medical guidance to the Medical Management department.

See all jobs on JobTailor

Health Systems Oncology Medical Affairs Director

Associate Medical Director

Medical Director – Family or Emergency Medicine

Oncology Field Medical Director

Medical Director

Medical Director

Medical Director – Medicaid

Senior Medical Director – Precertification

Chief Medical Officer