Horizon Blue Cross Blue Shield Looking for MDII Partner Transformation at Newark, New York Full Time

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Clinical leader in Horizon BCBSNJs strategic initiative to innovatively transform the way healthcare is delivered and reimbursed in NJ. Engage both internal and external leaders and stakeholders across all business units, to develop and operationalize strategies and technologies sharing information, assessing opportunities, facilitating change, and building bridges to help achieve our goal to improve quality and patient experience, while reducing overall costs, and change the way managed care organizations work with clinicians. Responsible for in depth data analysis and interpretation to identify opportunities designed to improve clinical outcomes, efficiency of care and patient experience Serve as a leader within and outside the organization to create and foster a culture of change.

Responsibilities:

• Collaborate with leaders across Perform leadership of HCM&T as well as government and commercial business units, to promote integration and increase effectiveness of medical management programs.
• Provide direct support to and work concurrently with Perform side of business enterprise to achieve targets.
• Play integral role with clinical transformation teams to achieve targets for quality of care and total medical expense.
• Lead the implementation of strategies with internal and external multidisciplinary teams to improve and enhance patient care, while reducing operational costs.
• Liaise with clinical leaders and non-clinician executives at health systems and flexible structure partners, building relationships, to set mutually agreed upon priorities with specific targets.
• Participate actively in work groups and leadership committees designed to improve patient care and enhance provider relationships
• Manage team-specific or department specific projects, including integration of new technologies and improvement of administrative efficiencies.
• Work directly with providers to educate them on best practices and improve overall quality of care by appropriate utilization of specific case management and/or disease management activities or interventions.
• Data interpretation and analysis to improve organizational and provider performance, including identifying cost trends in key areas.
• Serve as internal consultant/clinical resource within the organization to provide strategic support to all lines of business.
• Co-author publications and participate in internal and external presentations, collaborative initiatives and projects.
• Inspire a culture of continuous improvement for better quality of care with a focus on strategic planning initiatives and innovation.

Education/Experience:

• Requires an active and unrestrictive Doctor of Medicine or Doctor of Osteopathic Medicine license; NJ preferred.
• Requires a minimum of 10 (ten) years of experience in physicians specialty/field.
• Requires a minimum of 10 years experience in clinical practice.
• Requires a minimum five (5) years experience in managed care including medical management, quality management and network management.
• Experience in healthcare care delivery models development and operations.
• Experience in complex organization systems.

Additional licensing, certifications, registrations:

• Requires an active and unrestrictive Doctor of Medicine or Doctor of Osteopathic Medicine license; NJ preferred.
• Requires board certification (ABMS or AOA) in physician’s specialty.
• Requires valid drivers’ license.

Knowledge:

• Requires knowledge of healthcare care delivery models (PCMH, EOC, ACO).
• Requires knowledge of utilization management, case management, quality management, population health management, and network management.
• Requires experience or knowledge of facility, provider and ancillary contracting.
• Requires knowledge of accreditation requirements, NCQA, development of evidence based medical policies and criteria, CMS requirements, informatics, and provider profiling.
• Requires broad clinical skills to understand medical issues.
• Requires knowledge of group health insurance industry

Skills and Abilities:

• Requires strong ability to collaborate with peers including those involved in care delivery model practice recruitment, practice transformation, clinical data analytics, and technology
• Requires the ability to be accountable for implementation of value based programs and execution for results.
• Requires the ability to self-motivate and initiate business plans of action.
• Requires the ability to innovate and implement ideas in collaboration with both internal and external physician leaders.
• Requires ability to prioritize and multitask.
• Requires strong and effective verbal and written communication and presentation skills.
• Requires ability to work well within a team and act as team leader.
• Requires relationship building & networking skills.
• Requires the ability to exercise independent judgment in making medical necessity decisions.
• Requires the ability to interpret and apply medical policy and provide guidance to others.
• Requires the ability to analyze and interpret data.
• Requires demonstration of professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Requires proven ability to be innovative, goal oriented, possess strong problem solving skills and exercise sound judgment.
• Requires working knowledge of personal computers (proficiency with Word/Excel/Access) and supporting software in windows based environment including MS Office Products and email application systems.

Travel % (If Applicable):

• Travel within NJ/NY/PA required as needed.

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, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.