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　　Job Description

　　Our Behavioral Health team works closely with providers, employers, government, and health systems to improve the overall health of our members and transform the health care system. Behavioral Health is focused on improving quality, access, and value, helping our members get the care they need at the right time and in the right setting to meet their needs.

　　The Medical Director (Psychiatry) plays a pivotal role, and brings a unique set of knowledge and skills to the business of Blue Cross NC and frequently serves as an interface between physicians, providers, employer and community groups, and members as needed. This role utilizes clinical knowledge and experience to support value-based strategies, clinical operations and our organizational pursuit of high quality and cost-effective care for members.

　　What You'll Do

　　Provides medical oversight and expertise in appropriateness and medical necessity of healthcare services provided to Plan members.

　　Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care.

　　Evaluates authorization requests in timely support of nurse reviewers; reviews cases requiring concurrent review, and manages the denial process.

　　Educates and interacts with network and group providers and medical managers regarding utilization practices, guideline usage, pharmacy utilization and effective resource management.

　　Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.

　　Reviews quality referred issues, focused reviews and recommends corrective actions.

　　Develops and implements plan medical policies

　　Supports population health

　　Monitors appropriate care and services through continuum among hospitals, skilled nursing facilities and home care to ensure quality, cost-efficiency and continuity of care.

　　Ensures that medical decisions are rendered by qualified medical personnel, not influenced by fiscal or administrative management considerations, and that the care provided meets the standards for acceptable medical care.

　　Ensures that medical protocols and rules of conduct for plan medical personnel are followed.

　　Provides clinical expertise in support for quality improvement, sales, account, technology, investment and community engagement activities.

　　Works with Contracting Department in contract negotiation.

　　What You'll Bring (Hiring Requirements):

　　MD or DO in Psychiatry from an accredited medical school and completion of a residency training program.

　　10+ years of experience in the related field.

　　Current North Carolina medical license and/or Board certification in ABMS/AOA recognized specialty is advanced.

　　Occasional weekend work may be required.

　　It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.

　　Blue Cross NC is a fully taxed, not-for-profit North Carolina company with major operations centers in Durham and Winston-Salem. We employ more than 5,000 people who are passionate about health care, and we serve more than 4.3 million members.

　　Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

　　E-Verify

　　Our company uses E-Verify to confirm the employment eligibility of all newly hired employees. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview (https://www.e-verify.gov/employees/e-verify-overview) for English or Visión General de E-Verify (https://www.e-verify.gov/es/empleados/vision-general-de-e-verify) for Español.

　　Third Party Staffing Agencies

　　Blue Cross NC does not accept unsolicited resumes from any source other than directly from candidates. For the protection of all parties involved in the recruiting process, resumes will only be accepted from recruiters/agencies if a signed agreement is in place at the inception of the recruiting effort and authorized for a specific position. Unsolicited resumes sent to Blue Cross NC from recruiters/agencies do not constitute any type of relationship between the recruiter/agency and Blue Cross NC and do not obligate Blue Cross NC to pay fees if we hire from those resumes.