Medical Director – Medicare Advantage

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Advocate for and uphold the Mission Statement of BlueCross and BlueShield of Louisiana (BCBSLA).

• Evaluate treatment procedures and services to confirm they align with established guidelines or are supported by commonly accepted medical evidence when formal guidelines are absent.

• Provide operational guidance as necessary, particularly in utilization activities.

• Facilitate all physician and provider committees as required.

• Offer expertise on external contractual benefit matters.

• Engage with both physician and non-physician network providers on programs that may encompass: Performance Profiling, Disease State Management, Wellness, Medical Policy, and claims-related concerns.

• Participate in and bolster internal operations such as quality assurance initiatives, the BCBSLA Quality Improvement Plan, accreditation/URAC-related activities and requirements, medical policy, network operations, diversity initiatives, and similar programs.

⛳️ Requirements

• Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) is mandatory.

• A minimum of 7 years of clinical practice experience is necessary.

• At least 3 years of post-graduate experience involving direct patient care is required; 5 years of experience is preferred.

• Administrative experience within a health plan and/or familiarity with the insurance industry is preferred.

• Prior extensive experience in utilization, case, or disease management within a hospital or health plan environment is preferred.

• Experience with external accreditation organizations such as JCAHO, URAC, or NCQA is preferred.

• Medicare Advantage experience is preferred.

• A current medical license to practice in Louisiana that allows for the application of clinical judgment in evaluating an individual member’s clinical needs for utilization review determinations is required.

• Ability to secure a medical licensure for the state of Louisiana is required.

• Board certification in a specialty acknowledged by ABMS is required.

• Exceptional communication, presentation, interpersonal, and human relations skills are essential.

• Proficiency in Microsoft Office software including Word, Excel, Outlook, and PowerPoint is required.

🏝️ Benefits

• We make significant efforts to ensure our employees have the tools necessary to live well, maintain their health, continue their education, enhance their skills, advance professionally, and contribute to their local communities.