Medical Director in Southfield, MI at Accident Fund Holdings, Inc

Date Posted: 9/2/2020

Job Snapshot

Job Description

Formally reporting to the VP for Medicare STARs and Clinical Performance and taking direction from the health plans' president, the Medical Director, Medicare Clinical Oversight has a dual role with 50% effort providing oversight for key clinical and quality functions for Medicare Advantage health plans administered by Blue Cross Blue Shield of Michigan (BCBSM) Medicare Advantage subsidiary, Covantage, and 50% effort supporting clinical programs within BCBSM's own Medicare health plans. (S)he will also play an important role, as independent contributor, for several utilization management, care management, and quality improvement functions within Blue Cross Blue Shield of Michigan's Medicare plans. The Medical Director role is responsible for providing clinical oversight and support to areas across the organization, including Risk Adjustment, Health Management, and Quality.


Oversight of existing utilization management programs

  • Oversight of clinical staff performing direct utilization management, including...
    • Design of regular quality and performance metrics reporting
    • Review of regular quality and performance metrics reporting
    • Design and implementation of any quality improvement plans regarding utilization management functions
  • Provides final clinical decision-making for difficult cases when escalated by physician reviewers
  • Liaison with providers, state professional societies, and vendors performing utilization management

Participation in the development of Medical Policies

  • Participate in enterprise medical policy decision discussions and meetings
  • Educate staff who perform utilization review as to the proper interpretation of and use of extant medical policies
  • Bring forward concerns regarding medical policies, whether originally expressed by clinical staff or partner plans, for consideration within the appropriate governance within the BCBSM enterprise
  • Maintain working familiarity with CMS changes potentially influencing medical policies
  • Interpret and discuss medical policy positions with the following sorts of constituencies when necessary to either maintain implementation of a policy (defend it) or obtain information for use in potentially altering it:
  • Partner plan medical leadership
  • BCBM enterprise clinical personnel
  • Provider organizations, contracted and non-contracted (e.g., state medical societies) within covered areas

Provider Education

  • Delivers general education to providers relative to Medicare's risk adjustment model
  • Provides education to improve providers' performance in meeting quality measures as they pertain to Medicare's Stars rating
  • Holds targeted education sessions based on observed documentation trends and market-specific needs

Approval of the health plans' Quality Improvement Programs

  • BCBM enterprise clinical personnel
  • Bring forward any issues involving potential compliance issues for discussion by the appropriate BCBSM enterprise bodies
  • Participate in prioritization of clinical HEDIS and clinical pharmacy targets and in the ideation of STARs-related clinical interventions

Represent the Covantage plans in any BCBSM enterprise or external audits of processes related to clinical decision-making (utilization management) or STARs-related improvement efforts

General Clinical Support

  • Brings the provider's perspective into the development of products and materials across the organization
  • Supports the organization and its clients through various audits that require clinical input
  • Assists coders and PECs expand their clinical knowledge to improve their understanding of clinical documentation and facilitate their communication with providers in the field
  • Provides internal clinical education as needed to support continuous improvement
  • Participates in continuous improvement initiatives and provides clinical support to support overall program improvements across the organization
  • Participates in client and prospective client meetings to provide clinical support, as needed
  • Responsible for balancing workload to optimize the effectiveness of the department
  • Should be knowledgeable and able to perform utilization management duties.
  • Should be able to review unfavorable decisions made by the IRE and assists with building a case to reverse these decisions
  • Performs other work-related duties and responsibilities as directed, assigned, or requested

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

Job Requirements


Medical Doctor Degree (MD) or Doctor of Osteopathic Medicine (DO) required. Advanced degree, such as MBA, MHA, MPH, MMM, or a related field preferred. Board Certified in in a specialty approved by the American Board of Medical Specialists or the American Board of Osteopathy preferred. Current unrestricted State Doctor of Medicine (M.D.) or doctor of osteopathy (D.O.) license required. Continuous learning, as defined by the licensing body to maintain an active license, is required.

Certification in risk adjustment professional coding (CRC) from the American Association of Professional Coders (AAPC) is required.


Ten years of progressively more responsible experience strongly preferred in a healthcare environment with demonstrated technical experience that provides the necessary knowledge, skills and abilities. Five years of management or supervisory experience in healthcare strongly preferred. Medicare Advantage revenue experience strongly preferred. Health care practice experience providing services to Medicare Advantage and Medicaid patients required. Broad experience of the Medicare segment and an understanding of the overall Medicare risk adjustment and stars programs.


  • A capacity to implement tactically to consistently deliver results; well-developed skills in diplomacy and collaboration
  • Achievement of results through collaboration with divisions across large, complex organizations, and an ability to organize and manage multiple priorities
  • Excellent analytical, organizational and problem-solving skills, and senior level skills in managing ambiguous situations and issues.
  • Knowledge of activities, practices and terminology of the insurance industry
  • Ability to negotiate and establish a personal rapport with providers, and to resolve conflicts in a professional manner.
  • Ability to develop and implement effective and efficient recommendations.
  • Presentation skills and confidence to present company and product in one-on-one settings or to large gatherings.
  • A commitment to total customer satisfaction.
  • Demonstrates knowledge of documentation opportunities and clinical documentation requirements.
  • Excellent interpersonal and verbal and written communication skills.
  • Solid time management skills, including the ability to manage multiple activities and competing priorities.
  • Demonstrates leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
  • Ability to work with and empower others on a collaborative basis to ensure success of unit team.


Work is performed in an office setting with no unusual hazards. Requires transporting, pushing, pulling, and maneuvering items weighing up to 25 pounds. Travel required.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued, and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.


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