Mount Laurel, NJ
In this role, you will be accountable for providing day-to-day guidance, support and medical leadership for utilization management activities and decisions. You will also be responsible for analyzing data from a variety of sources to identify trends and/or issues.
• Provides medical expertise based on extensive knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols.
• Supports guides and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues or decisions.
• Supports guides and consults with nurse reviewers on case management issues or decisions.
• Supports guides and consults with nurse reviewers on medical necessity and medical appropriateness issues or decisions.
• Participates in the development, planning and management of complex cases and communicates management plan to the provider.
• Guides staff in the interpretation of medical policy. Assists in Medical policy and technology assessments and recommendations.
• Assists or consults on appeal review process.
• May provide input to provider credentialing, profiling and communication initiatives and network development.
• Participates on various internal or external committees as assigned.
• Requires knowledge in the principles and procedures of Utilization Management, the URAC Health UM Standards and peer review.
• Requires excellent understanding of the principles and concepts of managed care.
• Requires knowledge of the health insurance payor business, including operations.
• Requires broad clinical knowledge and understanding of current health care issues.
Skills and Abilities:
• Requires broad clinical skills to understand medical issues and to discuss them with physicians.
• Requires the ability to exercise independent judgement in making medical necessity decisions.
• Requires the ability to interpret and apply medical policy and provide guidance to others.
• Requires strong communication skills.
• Requires analytical skills to evaluate data from various sources to identify trends and issues.
• Requires board certification as an MD or DO with a current unrestricted license to practice medicine in Psychiatry.
• Requires a minimum of five years clinical experience as well as three or more years’ medical management in a managed care setting.
• Strongly prefer experience in Inpatient Psychiatry, Residential Mental Health/Partial Hospitalization/Intensive Outpatient Programs and solid knowledge of ASAM and Substance Use Disorder.
Special Licenses and Certifications:
• Active Unrestricted MD or DO License required; NJ license preferred.
• Requires board certification in Psychiatry with specialization in Addiction Medicine preferred.
Travel % (If Applicable):
• 20% travel within the state of New Jersey
We offer a highly competitive salary, dynamic work environment, and a comprehensive benefits package. For immediate consideration, please apply online and reference job requisition #RP022019-12375 at: www.HorizonBlue.com/Careers.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.
Blue Cross Blue Shield of New Jersey
Making Healthcare Work
While the New Jersey Psychiatric Association (NJPA) makes every effort to post accurate and reliable information, it does not guarantee that the information on this website is complete, accurate or up to date, nor does it assume responsibility for the use or application of any posted material. The NJPA takes no responsibility for any error, omission or other discrepancy between the electronic and any printed versions of documents. This website is intended solely for the purpose of electronically providing members, non-member psychiatrists and the public with information and convenient access to a variety of resources. The NJPA cannot provide specific advice or counsel, whether medical, legal or otherwise. This website links to websites maintained by other entities. Although efforts have been taken to assure that these linked websites are maintained by reputable organizations, the NJPA is not responsible for the information and opinions expressed in those linked sites.