Capital Blue Cross logo
Capital Blue Cross

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.” We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital, you will work alongside a caring team of supportive colleagues and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Medical Director – Utilization Management

Medical DirectorMedical DirectorPart TimeRemoteLeadTeam 1,001-5,000Since 1938H1B SponsorCompany SiteLinkedIn

Location

Pennsylvania

Posted

47 days ago

Salary

$100 - $150 / hour

Seniority

Lead

Professional Certificate5 yrs expEnglish

Job Description

• Conduct coverage reviews based on individual member plan benefits and national and proprietary coverage review policies. • Document clinical review findings, actions and outcomes in accordance with policies, and regulatory and accreditation requirements. • Engage with requesting providers as needed in peer-to-peer discussions. • Make medical necessity determinations on appeals and grievances, assuring that different reviewers conduct each level of review. • Support organizational accreditation efforts and regulatory review processes.

Job Requirements

  • 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.
  • Current unrestricted licensure in Pennsylvania as an MD or DO.
  • Appropriate Board Certification.
  • Knowledge of current and emerging medical treatment modalities.
  • Familiarity with National Committee for Quality/URAC standards.
  • Currently covered by, or eligible to be covered by, medical liability insurance.

Benefits

  • Health insurance
  • Flexible work arrangements
  • Professional development opportunities

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