Company: Capital Blue Cross
Posted on: January 7, 2022
The Medical Director provides medical guidance and support to
the full spectrum of Capital's Clinical Management activities and
programs. Chairs or participates in Capital's Clinical Management
Committees at the discretion of the Managing Medical Director.
Participates in strategic planning and other corporate projects for
Capital at the discretion of Senior Management. Represents Capital
in the medical provider community.
*This is an independently contracted position to accommodate both
schedule flexibility and the needs of the business.
Essential Duties and Responsibilities
- Supports the department with regard to the development, review,
and periodic updating of Capital's medical necessity policies.
- Helps to promote Capital's clinical vision and programs in the
local medical community and within Capital's 21-county service
- Serves as chair or participating member of Corporate Clinical
Management Committees at the direction of the Managing Medical
- Collaborates with, provides advice to, and directly supports
the Vice President of Medical Management and other Clinical
Management Staff on all clinical aspects of Capital's clinical
management programs, including Capital's Quality Management,
Prior-Authorization, Concurrent Review, Medical Claims Review, Case
Management, Disease Management, Pharmacy Management, and Health
- Provides Medical Director leadership to Vendor relationships as
directed by the Managing Medical Director.
- Supports organizational accreditation efforts and regulatory
- Reviews and analyzes utilization data and provides support to
Capital's Medical Informatics and Actuarial areas.
- Provides business requirements for information systems that
support medical director functions.
- Provides medical support to, and otherwise participates in,
high-level corporate leadership teams, including the Cross
Functional Senior Leadership Team and corporate special project
teams as requested.
- Provides or arranges for medical input and/or research
regarding best practices in the areas of medical policy
development, utilization management, quality management, benefit
administration, claims administration and provider
- Collaborates with local area medical leaders as requested by
the Managing Medical Director.
- Participates in the development of new or modified benefits for
inclusion in Capital's certificates of coverage. Effectively
collaborates with Capital's Marketing, Rating and Underwriting,
Legal, Customer Service, Provider Affairs, Benefits Management, and
- Assists with the development of Capital's provider networks and
partnerships at the direction of the Managing Medical
- Maintains a network of physician peer-review specialists to
assist Capital in making medical necessity determinations, benefit
determinations, quality of care determinations, and appeals and
grievances decisions involving medical decision making. Serves as
Capital's medical liaison with affiliated and/or subsidiary
- Makes coverage determinations in instances where requested
services do not meet medical necessity criteria or where benefit
exclusions require medical evaluation.
- Directs and reviews medical necessity determinations made by
contracted consulting physicians and other external reviewing
- Makes medical necessity determinations on appeals and
grievances, assuring that different reviewers conduct each level of
- Performs other related duties and assignments as directed.
- Additional Job Description
- Additional Job Description
- Knowledge of current and emerging medical treatment
- Familiarity with National Committee for Quality Assurance
- Demonstrated public speaking and written communication
- A minimum of five years clinical experience, post residency,
including both inpatient and outpatient care.
- At least three years' experience in managed care, utilization
review, and/or quality management.
- Minimum of three years' experience in a management or
leadership position in the health care industry.
- PC literacy and ability to perform electronic research and
respond to electronic requests.
Education, Certification, and Licenses:
- Minimum requirements include an MD or DO Degree, as well as
appropriate Board Certification.
- Current unrestricted licensure in Pennsylvania as an MD or
- Currently covered by, or eligible to be covered by, medical
- Current valid Pennsylvania drivers' license to travel to and
from provider/member/customer locations.
Keywords: Capital Blue Cross, Harrisburg , Medical Director, Executive , Harrisburg, Pennsylvania
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