Blue Cross and Blue Shield of Nebraska (BCBSNE) Overview
BCBSNE has provided healthcare coverage and peace of mind to Nebraskans for more than 85 years, offering group health, individual plans, dental, and Medicare solutions. As part of a nationwide association, the Blue Cross and Blue Shield brand represents the nation's largest and most experienced healthcare benefit companies, serving 600,000+ people in Nebraska. The organization serves members locally through extensive provider networks and nationally through the BlueCard program.
Role Summary
The Medicare Medical Director is responsible for clinical, quality, care management, and population health outcomes and cost for the Medicare population. The Medical Director will lead development and implementation of strategies that promote practice transformation, patient satisfaction, improve quality and outccoms, while reduce overall cost for a Medicare Advantage population.
Key Outcome / Responsibilities:
- Oversight of clinical, quality, care management, and population health outcomes and cost for the Medicare population
- Assess areas of greatest opportunity within the Medicare population and identify areas for potential changes, enhancements, or new programs
- Lead clinical engagement in assigned market(s), partnering with the Chief Medical Officer to drive quality and care management performance improvement in primary and specialty care settings
- Improve provider clinical documentation or burden of illness capture (Risk Adjustment) to ensure best clinical care of members/patients
- Develop relationships with physicians and staff to engage, identify, and disseminate best practices, analyze clinical workflows, and support intervention activities directed towards meaningful quality improvements and reduction of unplanned health care utilization
- Collaborate with key organizational partners and their teams to optimize quality and clinical initiatives and drive improvements across the Medicare population
- Act as lead business and clinical liaison to network providers and facilities to support the effective execution of Medicare medical services programs
- Provide alternative approaches that can improve practice performance while achieving similar or greater clinical quality
- Develop and maintain strategic relationships with internal and external stakeholders involved with the care and management of the Medicare population
Specific Skills, Knowledge & Capabilities:
- Experience with utilization review/quality assurance, and direct case management
- Demonstrated skills in creating buy-in with internal and external clinician stakeholders to transform clinical care
- Additional Training: preferred residency in an adult primary care specialty (family medicine, general internal medicine, geriatric medicine, combined internal medicine/peds)
Qualifications Required:
- Doctor of Medicine (M.D or D.O)
- Board Certified in an American Board of Medical Specialties Board, and a current, unrestricted license to practice medicine in a state or territory of the United States, including post graduate direct patient care experience required
- 7+ years of direct clinical (patient care) experience, with consideration given to quality improvement activities, participation in cost containment initiatives and other population health experiences
- 2+ years of managed care experience, preferably with a Medicare Advantage population