Director, Medical Policy Value & Implementation Job:
Blue Cross and Blue Shield of Minnesota

23218-en_US
Blue Cross and Blue Shield of Minnesota
Eagan Minnesota
Healthcare
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Description

About Blue Cross



 



For more than 80 years, Blue Cross and Blue Shield of Minnesota has been passionate about improving health. We’ve been guided by our Mission of making a healthy difference in people’s lives and have earned a reputation for innovation and service. Going forward we are committed to extending our reach outside of Minnesota and broadening our impact beyond our core health insurance business. Our Vision of being a national leader in consumer health will be driven by our new enterprise brand, Stella, and a strategy that spans a portfolio of diversified businesses and brands, including BCBSMN, to add value to consumers throughout their healthcare journey. We are dedicated to building on our legacy of leadership in Minnesota and expanding our platform to make a healthy difference in people’s lives.



 



We offer our employees a comprehensive benefits, compensation and total rewards package to keep you and your family healthy and to secure your financial future. Our Employee Resource Groups help us advance health equity while promoting a diverse and inclusive work environment. Join us and make a healthy difference in people’s lives through the work you do every day. Together, we’ll make the healthcare experience better for everyone!


Description Summary

This position is responsible for providing strategic direction and oversight of all aspects of Medical Policy (MP) and the operational design of Utilization Management (UM).  The scope includes: medical policy design (research and development), implementation, evaluation and maintenance; in addition, utilization management program management, and integration of medical policy and utilization management strategies.  The position has accountability for the MP Research and Development team, MP Implementation team and UM program management team.  Line of Business scope of accountability includes commercial and government programs. This position will be accountable for: 1) overseeing implementation for corporate policy and process for medical provider and other reimbursements, 2) ensuring that all claims are reviewed, settled, and processed in compliance with and according to contract provisions and regulatory requirements, 3) evaluating and developing policies and provider reimbursement guidelines to effectively manage and control medical claims cost, 4) aligning Medical Policy with Utilization Management operations and strategy, 5) designing, developing and communicating shared MP and UM operational capabilities and services, and 6) delivering services within the triple aim focus of improving population health, improving member experience of care and lowering the per capita cost of care.


Accountabilities


  1. Works closely with Care Management executive leadership and dedicated Medical Director to set the overall strategic direction for Medical Policy and Utilization Management; and is responsible for: medical technology assessment process; medical, behavioral, and medical pharmacy policy development process and the committee processes that support approval; coverage determination process; policy communication, training, claims set-up, and other ancillary operational implementations.

  2. Collaborates with Corporate Compliance to inform Medical Affairs and Care Management staff of new state and federal laws and regulations, and changes to existing laws and regulations that impact commercial and government programs.

  3. Oversees regulatory policy development and approval for Medical Affairs and Care Management, compliance monitoring, and other regulatory reporting.

  4. Provides project leadership in development and implementation and ongoing monitoring of corrective action plans resulting from internal or external audit deficiencies.

  5. Defines and directs the implementation of major projects within the division and across the corporation.

  6. Identifies processes within areas of accountability that are operationally inefficient. Identifies the appropriate owners within the division and collaborates with them to develop innovative approaches for change and resolution.

  7. Leads the collaborative effort with Care Management leadership and dedicated Medical Director to set the direction for the peer review department.

  8. Working with Care Management Operations and Data Intelligence, ensures that the peer review contracting and processes follow regulatory statutes and that peer review coverage is available for case review.

  9. Direct the medical policy clinical evaluation coupled with UM program development and evaluation resulting in the creation of new and/or adjustment and retirement of Medical Policy and associated UM services.

  10. Direct the creation of the UM program value story which includes the development and maintenance of a program capability roadmap, maintaining the reporting metrics and the intentional combination of metrics to share the program value and performance.  

  11. Direct the completion and maintenance of UM program description & evaluation documentation and UM business rules repository.

  12. Manages the department including interviewing and hiring employees following required EEO and Affirmative Action guidelines and ensuring employees receive the proper training. Conducts performance evaluation, and is responsible for managing employees, including skill and career development, policy administration, coaching on performance management and behavior, employee relations and cost control. Manages department budget.


Requirements

Accepting this director level position at BCBSMN requires signing an Employee Confidentiality, Intellectual Property Assignment and Restrictive Covenants Agreement as a condition of employment.




  • Bachelor’s degree in health care field and 8 years of related work experience that includes health plan/care management processes and direct experience with the technology assessment process and medical policy development process.

  • 3 years of management experience.

  • Broad knowledge of the managed care and health care/insurance industry.

  • Strong, demonstrated leadership and communication skills.

  • Demonstrated ability in developing and implementing strategic initiatives.

  • Demonstrated ability to collaborate with and influence others.

  • Proven ability to exercise good judgment and make independent decisions.

  • Demonstrated knowledge, skills, and abilities in a leadership role.

  • Critical thinking skills with proven ability to identify and implement process improvements.

  • Effective verbal and written communication skills.

  • In depth understanding of medical claims and coding.


Preferred Requirements


  • Master's Degree in Business, major Public Health Administration and Policy, Health Services Research and Policy, or Health Administration.

  • Health Care Compliance experience preferred.


FLSA Status

Exempt


Make a difference



 



Thank you for your interest in Blue Cross. Be part of a company that lets you be you — and make a healthy difference in people’s lives every day



 



Blue Cross is an Equal Opportunity and Affirmative Action employer that values diversity. All qualified applicants will receive consideration for employment without regard to, and will not be discriminated against based on race, color, creed, religion, sex, national origin, genetic information, marital status, status with regard to public assistance, disability, age, veteran status, sexual orientation, gender identity, or any other legally protected characteristic.

Basic Qualifications
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