Resp & Qualifications
PURPOSE: Provides clinical support and directs daily departmental activities that generally include care management, interpreting medical policy, quality improvement, disease management, utilization review, and medical claims review. Plans and coordinates functions with other departments and interfaces with internal and external customers.
In house expert on all the above aspects as they specifically pertain to Medicare Advantage .
PRINCIPAL ACCOUNTABILITIES: Under the supervision of the CMO
Directs daily clinical, operational and administrative activities for CareFirst with special attention and focus on Medicare Advantage lines of business
Establishes goals, objectives and standards for CareFirst;
Interprets and implements policies and procedures to monitor overall efficiency and adherence standards for department for CareFirst;
Serves as a liaison with other departments and divisions for development and implementation of programs, products and activities;
Liaison to other departments and divisions for interpretation of Medical Affairs policies and practices;
Develops and implements programs for education of affiliated providers;
Serves as clinical and administrative resource and ensures adherence to policies, procedures and external regulatory agencies.
Medical Degree from an accredited medical school, completion of an American residency program required with postgraduate training.
Minimum of 5 years clinical practice experience or equivalent.
2 years health plan experience with Medicare Advantage including STARS and Care Management
Current license to practice in Maryland without restriction. ( or ability to obtain expeditiously)
Excellent organizational skills and communication skills, both verbal and written. Strong interpersonal skills needed.
Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 10/31/19
Federal Disc/Physical Demand
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities.
The employee is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The employee must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship