Are you a board-certified physician ready to take the next step in your leadership journey? We're looking for a dynamic and experienced clinical leader to join our team as Lead Medical Review Director-a pivotal role with a clear path toward Chief Medical Officer responsibilities.

This is more than a medical director role. It's an opportunity to shape the future of care for Medicare Advantage and Dual Eligible populations, lead multidisciplinary teams, and influence policy, quality, and performance at scale.

What You'll Do:

Lead medical necessity reviews, appeals, and peer-to-peer consultations

Supervise and mentor a team of Medical Directors in utilization and case management

Collaborate on medical policy development and coding accuracy

Identify and report quality of care concerns

Partner with Value-Based Care organizations to optimize utilization

Analyze clinical trends and cost drivers to inform strategy

Receive direct mentorship and training in CMO-level responsibilities

What We're Looking For:

Board-certified physician with at least 5 years of clinical experience in managed care settings

Proven leadership in Medicare Advantage and Dual Eligible populations

Experience supervising multidisciplinary clinical teams

Strong background in quality improvement, utilization management, appeals and grievances, and clinical operations

Insurance industry experience is a plus, but not required

Passion for innovation, collaboration, and improving patient outcomes

Why Join Us?

CMO Successor Role: Step into a leadership pipeline with structured development and executive mentorship

Mission-Driven Work: Improve care quality and access for vulnerable populations

Collaborative Culture: Work with a team of forward-thinking clinicians and healthcare leaders

Strategic Impact: Influence policy, programs, and performance across the organization

If you're ready to lead with purpose and grow into a top executive role, we want to hear from you.

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:

Employee

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.

About Us

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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