Director Medical Management
Blue Cross Blue Shield of Michigan

Job Info

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Provide leadership, direction and oversight of the organization's medical programs, including but not limited to utilization management (including in and outpatient prior authorization and referral programs), care management programs (including case management, disease management and care coordination that support Blue Cross Blue Shield of MI, Blue Care Network and any subsidiaries.

• Provide leadership, direction and oversight for medical clinical programs, including utilization and care management activities for BCBSM members and potential subsidiaries.
• Develop, manage and monitor the department budget to ensure resources are effectively and efficiently utilized.
• Develop and ensure processes, policies and programs comply with regulatory and accreditation agency standards, including but not limited to National Committee for Quality Assurance (NCQA), Michigan Department of Community Health (MDCH), Centers for Medicare and Medicaid Services (CMS) and Department of Insurance and Financial Services (DIFS).
• Collaborate with other areas such as Quality Management, Medical Informatics and Pharmacy on various member health activities.
• Develop, implement, monitor and evaluate programs to improve member health status, member access to care and member, practioner and purchaser satisfaction.
• Assist in the development, monitoring, analysis and reporting of utilization and other key statistics to senior leadership.
• Monitor and take action to improve provider use of clinical resources, conformance to contractual agreements and cost containment activities.
• Implement and manage care management system to ensure efficiencies and updated requirements to support medical management programs

"Qualifications"

EDUCATION AND/OR EXPERIENCE

• Registered Nurse with current unrestricted Michigan license. Bachelor's degree required. Master's degree preferred.
• Five (5) years' experience in a leadership role with responsibility for medical management in a health care environment.
• Extensive knowledge of accreditation and regulatory requirements and applicable standards related to NCQA, CMS, DIFS and MDCH. Knowledge of utilization, disease, case management strategies, including behavioral health.

OTHER SKILLS AND ABILITIES

• Extensive and direct experience in all areas of medical management.
• Working knowledge of conceptual framework of medical management, including structure, process and outcome methods of measurement, CQI systems.
• Demonstrated success in planning, conducting and completing major project activities.
• Effective written and oral communication skills.
• Demonstrated ability to work with conflicting priorities, non-clinical executives, organizing and managing diverse service/support demands and effectively delegating and overseeing work assignments.
• Other related skills and/or abilities may be required to perform this job.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

This job has expired.