at Health Care Service Corporation in Chicago, Illinois, United States
Job Description
At HCSC, we consider our employees the cornerstone of our business and the foundation to our success. We enable employees to craft their career with curated development plans that set their learning path to a rewarding and fulfilling career.
Come join us and be part of a purpose driven company who is invested in your future!
Job Summary
Internal physician LOB subject matter expertise for all aspects of the relevant clinical regulatory and NCQA requirements
Physician representative for high-cost claim reviews / clinical claim trending / payment integrity strategy
Clinical quality oversight, including QOC reviews, QIC participation, QAPI development, participation in key clinical quality workgroups
Utilization management support and oversight for initial determinations and appeals, including ALJ and state fair hearings, member/provider/state escalations
Clinical advisory support for audit readiness with state, EQRO and CMS
Population health innovation ideation for LOB clinical programming (e.g. disease management, health equity), data analytics and technology
Clinical advisory role for value-based care strategy & network development physician support
Centralized LOB physician resource for provider network interaction model, including participation in JOCs, supporting escalations.
Participation in RFPs, broker/sales calls as the LOB physician representative
Participates in and liaises with applicable regulatory agencies as the LOB physician representative for any relevant clinical matters
Provides LOB specific vendor & IRO oversight, including participation in vendor meetings (JOCs, clinical case reviews) and providing targeting monitoring and physician review for clinical audits
Support of any external facing education materials, including development of clinical guidelines and any materials developed to support members and providers
Requirements:
UM experience
Resident of Illinois
Training or education in Public Health
JOB REQUIREMENTS:.
Physician (M.D. or D.O) with a current and unrestricted physician license in a state or territory of the United States
Maintain Board Certification by a specialty board approved by the American Board of Medical Specialties, National Board of Physicians and Surgeons, or the Advisory Board of Osteopathic Specialists
5 years of clinical experience
Analytical and communication skills
Strategic thinking skills
Proficiency in computer skills (including software applications such as Microsoft Office Product and Lotus Notes) needed for electronic documentation of case reviews
UM experience
Resident of Illinois
Training or education in Public Health
PREFERRED REQUIREMENTS:
3 years Managed Care experience
Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!
HCSC Employment Statement:
HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
BCBSTX complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
