Summary

Why should you join the BlueCross BlueShield of South Carolina family of companies

Other companies come and go but weve been part of the national landscape for more than seven decades with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina and much more. We are one of the nations leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy consider joining our team!

Position Purpose:

As the Vice President of Medical Affairs you will provide direct physician support to all areas of commercial lines of business including but not limited to: Preferred Blue FEP Health Care Services and National Alliance this role you will function in a consultant capacity to other areas of the company including Corporate Audit the various claims areas Marketing Benefit Files and Underwriting. Additional responsibilities include case evaluation case escalations complaint review training and policy development as well as providing medical support to the quality management program of all commercial products.

The Vice President of Medical Affairs is also the Medical Director to the State HealthPlan performing all of the functions that are listed for Preferred Blue and FEP with responsibility for Post Service Medical Review of all claims appealed in Preferred Blue FEP and The State this position you will also provide medical support to Companion Life. The Vice President of Medical Affairs will serve as the Chair of the Medical Policy Committee and the Co-Chair of the Gene Therapy Task Force along with the pharmacy leadership.

We seek a strong physician leader with managed care or payer experience who will continue to build upon the foundation of enhanced transparency of medical policy that weve built. The ideal candidate will possess exceptional communication and relationship-building skills in a highly matrixed organization.

Description

Location: This position is full-time (40-hours/week) Monday-Friday ON-SITE at our 4101 Percival Road Columbia SC 29229 location.

What Youll Do:

• Provides direct physician support to all commercial lines of business including but not limited to Preferred Blue FEP State HealthPlan and National Alliance utilization and case management functions such as pre-admission review continued stat review individual case management and individual surgical procedure certification.

• Supervises the activities of the Physician Advisors.

• Provides oversight of Physician support team for National Alliance and Major Group client support.

• Develops maintains and implements corporate medical claims payment policy.

• Provides medical support to Preferred Blue/FEP Quality Programs to facilitate compliance with all SC Department of Insurance regulations and/or NAIC recommended standards and to ensure maintenance of a total quality management program that meets or exceeds the requirements for accreditation of Preferred Blue and FEP by national quality associations (i.e. URAC or NCQA).

• Assesses reports and information generated by Utilization Management Case Management Provider Profiling Provider Services and other internal functions to determine the extent and evaluate the impact of underutilization and overutilization of important aspects of care and service.

• Serves as consultant to provide input regarding complex case management in Preferred Blue.

• Supervises the Activities of the Post Service Medical Management area which includes the development of claims payment policy and the review of post service claims review and appeals.

• Assists in the Credentialing of providers for the BCBSSC networks. Reviews all problems files.

• Participates as a voting member of CBA Medical Advisory Committee.

• Provides direct physician support to Underwriting and Corporate Audit and provides medical consulting support to Companion Life on request.

• Serves as a corporate liaison for Blue Cross Blue Shield of SC as a member of various external organizations.

• Directs the performance of surveys audits and outcome analyses and reviews those issues identified by the prioritization process gathering the results of these activities and writing reports concerning the outcomes.

• Facilitates linkage between quality improvement and other management functions within the Plan e.g. network modifications benefits redesign medical management systems proactive feedback to providers patient education programs etc.

• Serves as Chairperson of the Quality Medical Advisory Committee (QMAC) responsible for assessment of functions and development and implementation of standards in the following areas: Quality Improvement Utilization Management Case Management Credentialing/Re-credentialing Members Right and Responsibilities Preventive Health Services and Medical Records.

• Completes review of all providers applying for network participation to ensure the quality of providers accepted and ensure qualified clinicians are accountable to the organization for decisions affecting our members.

To Qualify For This Position Youll Need The Following:

• Required Education: Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) required.

• Required Experience:10 Years Broad clinical experience and a strong knowledge of quality assurance and risk management.

• Required Training: An active unrestricted medical license from the United States and current board certification in a recognized specialty.

We Prefer That You Have The Following:

• 3-5 years of Managed care experience.

• Masters in Business Administration or Medical Management or Healthcare related field.

• Certified Physician Executive (CPE) Care Management Physician Certification (CMPC) and/or Certified in Health Care Quality and Management (CHCQM) Preferred

• Executive level presentation skills.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans dental and vision coverage

• 401k retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

• National discounts to movies theaters zoos theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next:

After submitting your application our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age race color national origin sex religion veteran status disability weight sexual orientation gender identity genetic information or any other legally protected status. Additionally as a federal contractor the company maintains affirmative action programs to promote employment opportunities for individuals with disabilitiesand protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities pregnant individuals individuals with pregnancy-related conditions and individuals needing accommodations for sincerely held religious beliefs provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment please email or call ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Heres moreinformation.

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