Blue Cross & Blue Shield of Rhode Island hiring Senior Medical Director in Providence, RI | LinkedIn (2024)

Please email hr_business_partners@bcbsri.org if you are a candidate seeking a reasonable accommodation for the application and/or interview process.

Schedule : Remote or Hybrid (New England Area)

Compensation: $263,200 - $438,800

Jump into the new world of health insurance:At Blue Cross & Blue Shield of Rhode Island (BCBSRI), our business is healthcare. But our focus is on improving lives. Be part of a team that is large enough to make a difference but small enough to be innovative. Work in a rapidly changing field. Take a chance to be creative. Move outside the status quo. Shape new ideas with the power of a national brand behind you.

Join others who know diversity is strength: We appreciate and celebrate everything that makes us unique: age, national origin, citizenship status, perspectives, experiences, physical or mental disability, military status, race, ethnicity, religion, gender, sexual orientation, gender identity and/or expression. Our diversity strengthens us as an organization and helps us better serve an increasingly diverse Rhode Island population.

Why this job matters: The Senior Medical Director at BCBSRI will ensure the quality management programs supports BCBSRI’s strategic priorities and improves quality of care and outcomes for members. The Senior Medical Director will provide clinical support for the government programs segments. This individual will report to the BCBSRI Chief Medical Officer and provide clinical insight and direction into the following areas: legal, regulatory, sales, product, communications, and others as necessary.

What you will do:

• Provide clinical oversight over components of quality management program inclusive of provider and hospital quality incentive programs, health plan accreditation and quality improvement initiatives. Provide oversight, medical expertise administrative guidance to ensure that all Plan operations and goals for quality, value and cost management are met by the program.
• Provide clinical guidance to ensure plan objectives for HEDIS, CAPHS and CMS Stars are met
• Establish and maintain up to date and industry-based quality performance standards and ensure quality management program aligns with BCBSRI strategic goals related to health equity.
• This individual will also support cross-functional business area leaders and represent the CMO and/or his Chief of Staff at meetings and on committees, as appropriate.
• Serve as a physician liaison to local and national organizations inclusive of RI Dept of Health, Office of the Health Insurance Commissioner (OHIC), EOHHS, and CMS. Represent the company at the Blue Cross Blue Shield Association committees as needed. Advise senior management on clinical matters.
• Develop, implement, and monitor clinical guidelines, protocols and programs that accomplish Plan objectives and that meet the medical needs of the member community and the financial needs of the provider community.
• Perform medical necessity review determinations as needed. Collaborate with internal stakeholders to develop and implement utilization review programs and initiatives that improve member care in a cost-effective manner.
• Conduct appeals reviews of medical appropriateness and levels of care as needed in accordance with state laws, regulations, and accrediting bodies.
• Build relationships with physicians, hospital executives, and other providers to improve collaboration, provide education, and align interests.
• Other responsibilities as assigned.

What you need to succeed:

• Current or willingness to obtain, unrestricted license to practice as a physician in Rhode Island
• Eight or more years post-graduate experience in private practice with direct patient care
• 3-5 years’ experience as a Medical Director in a health plan or similar managed care entity with experience with Medicaid or Duals membership
• Board Certification in ABMS certified specialty.
• Proficiency with Microsoft Office: Microsoft Word, Excel, Power Point
• Managed Care
• Utilization Review
• Quality Improvement
• Analytics and Medical Informatics
• Quality Contracting
• Excellent Verbal and written communication skills
• Handle multiple priorities
• Exercise sound judgment.
• Take initiative in finding solutions to difficult and/or sensitive problems

Preferred Extras:

• Knowledge of CMS Medicare Advantage regulations, RI Medicaid regulations, NCQA standards, RIDOH regulations
• Knowledge of quality improvement principles and utilization improvement policies and methods to change provider behavior
• Knowledge of finance and reimbursem*nt methodologies

Location: BCBSRI is headquartered in downtown Providence, conveniently located near the train station and bus terminal. We actively support associate well-being and work/life balance and offer the following schedules, based on role:

• In-office: onsite 5 days per week
• Hybrid: onsite 2-4 days per week
• Remote: onsite 0-1 days per week. Permitted to reside in the following New England States: CT, RI, MA

At Blue Cross & Blue Shield of Rhode Island (BCBSRI), diversity and inclusion are central to our core values and strengthen our ability to meet the challenges of today's healthcare industry. BCBSRI is an equal opportunity, affirmative action employer. We provide equal opportunities without regard to race, color, religion, gender, age, national origin, disability, veteran status, sexual orientation, genetic information and gender identity or expression.

The law requires an employer to post notices describing the Federal laws prohibiting job discrimination based on race, color, sex, national origin, religion, age, equal pay, disability, veteran status, sexual orientation, and genetic information and gender identity or expression. Please visit https://www.eeoc.gov/employers/eeo-law-poster to view the "EEO is the Law" poster.

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