Medical 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

• Perform concurrent and prior authorization reviews with peer to peer coverage of denials.
• Perform appeals in their 'base plans' and may round robin based on 'same or similar specialty' needs.
• Perform pharmacy reviews.
• Participate in and be able to lead rounds.

Medical Director – Duals Center of Excellence

• perform concurrent and prior authorization reviews with peer to peer coverage of denials.
• perform appeals in their 'base plans' and may round robin based on 'same or similar specialty' needs.
• perform pharmacy reviews.
• participate in and be able to lead rounds.

Medical Director – Aetna Duals Center of Excellence

• 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.

See all jobs on JobTailor

Associate Medical Director

Medical Director – Duals Center of Excellence

Medical Director – Aetna Duals Center of Excellence

Senior Medical Director – Precertification