Job Responsibilities

Develop and administer inter-reviewer reliability methodology to ensure medical necessity determinations are consistent with CMS published guidelines corporate medical review criteria, and medical policy guidelines.

Analyze, evaluate and apply clinical metrics that produce actionable information in support of medical management and quality improvement initiatives.

Direct and support physician review to ensure timeliness, accuracy and reliability of UM and Appeals reviews.

Lead and serve on various committees in order to accomplish medical utilization, cost and quality objectives of BCBST.

Willingness to travel within the State of Tennessee and nationally.

Job Qualifications

Education

Current MD or DO degree with an unencumbered and unrestricted license to practice medicine in Tennessee required. *However, this requirement can be waived for jobs where the totality of the incumbents duties and responsibilities are restricted to the performance of administrative duties only.

Based on business need, an unencumbered and unrestricted license in an alternative state may be substituted.

Experience

5 years - Clinical experience required

5 years - Healthcare administration and/or UM experience preferred

Skills\Certifications

Board Certification in a recognized specialty by the American Board of Medical Specialties or the American Board of Osteopathic Specialists

Ability to conceive and deliver innovative solutions

Ability to work independently with minimal supervision or function in a team environment sharing responsibility, roles and accountability.

Outstanding negotiation, presentation, and facilitation skills

Proficient in Microsoft Office (Outlook, Word, Excel and Powerpoint)

Ability to interpret and explain complex government policies

Knowledge of Medicare programs

Employees who are required to operate either a BCBST-owned vehicle or a personal or rental vehicle for company business on a routine basis will be automatically enrolled into the BCBST Driver Safety Program. The employee will also be required to adhere to the guidelines set forth through the program. This includes, maintaining a valid driver's license, auto insurance compliance with minimum liability requirements; as defined in the "Use of Non BCBST-Owned Vehicle" Policy (for employees driving personal or rental vehicles only); and maintaining an acceptable motor vehicle record (MVR). The definition for "routine basis" is defined as daily, weekly or at regularly schedule times.

Number of Openings Available

Worker Type:

Consultant

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices (https://www.bcbst.com/docs/equal-employment-opportunity.pdf)

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

As Tennessee's largest health benefit plan company, we've been helping Tennesseans find their own unique paths to good health since 1945. More than that, we're your neighbors and friends - fellow Tennesseans with deep roots of caring tradition, a focused approach to physical, financial and community good health for today, and a bright outlook for an even healthier tomorrow.

At BCBST, we empower our employees to thrive both independently and collaboratively, creating a collective impact on the lives of our members. We seek talented individuals who excel in a team environment, share responsibility, and embrace accountability.

We're also seeking candidates who are proficient in the Microsoft Office suite, including Microsoft Teams, organized, and capable of managing multiple assignments or projects simultaneously. Additional, strong interpersonal abilities along with strong oral and written communication skills are important across all roles at BCBST.

BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based.

BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense.If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.

BlueCross BlueShield of Tennessee

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