[Hiring] Assistant Medical Director @Premera Blue Cross

Role Description

As the Assistant Medical Director, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including a review of clinical documentation using medical policy criteria, guidelines, and member contracts at Premera Blue Cross.

The Assistant Medical Director supports clinical programs (disease and case management), and the review and adoption of health plan developed review criteria.

What you will do:

• Perform clinical review of various case types as assigned, including pre-service, post-service, and concurrent behavioral health services.
• Consult with clinical staff on specific case reviews.
• Act as the final decision maker for coverage decisions based on medical necessity, investigational status, contractual exclusion, or network structure.
• Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determinations.
• Consult with nursing and other clinical staff to assess and explore care options for members enrolled.
• Participate in the development, annual review, and approval of company medical review criteria as a Premera Medical Policy Committee member.
• Participate in Inter-Rater Reliability evaluations to ensure consistency in clinical decision-making.
• Respond in a professional manner to all requests for consultation from within Premera Blue Cross and from contracted practitioners and facilities.
• Support member and provider appeals by participating in the appeals process and conducting secondary reviews as needed.
• Fulfill all professional continuing education requirements and participate in ongoing education/training as appropriate.

This role will be part-time, 20 hours a week.

Qualifications

• Licensed Physician with an MD or DO degree (Required)
• Unrestricted Washington MD or Alaska DO state licensure, or ability to obtain within 90 days.
• Current board certification in psychiatry from the American Board of Psychiatry and Neurology.
• Five (5) years of clinical experience in psychiatry (Required)
• Previous experience performing medical necessity and clinical reviews in a health plan setting. (Preferred)
• Familiarity or experience with clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines) or InterQual. (Preferred)
• Familiarity or experience with CPT, ICD, and HCPCS code sets and resource-based relative value scale (RBRVS) pricing concepts. (Preferred)

Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service.
• Wellness incentives with a wide range of mental well-being resources for you and your dependents.
• Generous paid time off to reenergize.
• Tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.
• On-campus model provides flexibility with access to on-site resources and networking opportunities.
• Commuter perks to lessen environmental impact and costs.
• Free convenient on-site parking.
• Subsidized on-campus cafes for affordable lunchtime connections.
• Engaging on-site activities such as health and wellness events.
• Complementary fitness & well-being center offering in-person and virtual workouts.