This position is accountable for providing day-to-day guidance, support and medical leadership for utilization management activities and decisions. This position is responsible for supporting the Chief Medical Director in all aspects of utilization management. Analyzes data from a variety of sources to identify trends and/or issues. Participates on various internal or external committees as assigned.
Provides medical expertise based on extensive knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols.
Supports, guides and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues or decisions.
Supports, guides and consults with nurse reviewers on case management issues or decisions.
Supports, guides and consults with nurse reviewers on medical necessity and medical appropriateness issues or decisions.
Participates in the development, planning and management of complex cases and communicates management plan to the provider.
Guides staff in the interpretation of medical policy. Assists in Medical policy and technology assessments and recommendations.
Assists or consults on appeal review process.
May provide input to provider credentialing, profiling and communication initiatives and network development.
Analyzes data from a variety of sources to identify trends and/or issues.
Participates on various internal or external committees as assigned.
Requires knowledge in the principles and procedures of Utilization Management, the URAC Health UM Standards and peer review.
Requires excellent understanding of the principles and concepts of managed care.
Requires knowledge of the health insurance payor business, including operations.
Requires broad clinical knowledge and understanding of current health care issues.
Skills and Abilities:
Requires broad clinical skills to understand medical issues and to discuss them with physicians.
Requires the ability to exercise independent judgement in making medical necessity decisions.
Requires the ability to interpret and apply medical policy and provide guidance to others.
Requires strong communication skills.
Requires analytical skills to evaluate data from various sources to identify trends and issues.
Requires a minimum of five years clinical experience and three or more years medical/utilization management in a managed care setting.
Strongly prefer experience in Inpatient Psychiatry, Residential Mental Health/Partial Hospitalization/Intensive Outpatient Programs and solid knowledge of ASAM and Substance Use Disorder.
Special Licenses and Certifications:
Active Unrestricted NJ MD or DO License Required
Requires board certification in Psychiatry.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.
Horizon Blue Cross Blue Shield