HORIZON Blue Cross Blue Shield of New Jersey (Newark/Mount Laurel, NJ)

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Medical Director

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February 26 - April 27

Behavioral Health
Newark, NJ
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


February 26
April 27
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