We have been named one of the Best Places to Work in PA!
Capital BlueCross is the leading health solutions and insurance company in Central Pennsylvania and the Lehigh Valley. As a partner in the community’s health for 80 years, we offer health insurance products, services, and innovative technology solutions that provide peace of mind to consumers and promote health and wellness for our customers.
Headquartered in Harrisburg, Pa., this capital city offers something for everyone, including access to the outdoors, with mountains, rivers and streams close by, and shore points within a half day’s drive. Major east coast cities such as Philadelphia, New York, Baltimore, and Washington, D.C. are just a few hours away by car. The area is also bolstered by multiple colleges and universities offering top notch higher education. A lively arts scene is enjoyed in the Harrisburg area as well as a variety of family entertainment venues, including amusement parks and sports arenas that make the area an ideal location for families.
More than a health insurer, the company delivers innovative solutions through a family of diversified businesses that is creating a healthier future and lowering health care costs. Among these solutions are patient-focused care models, leading-edge data analytics, and digital health technologies.
We seek a board-certified MD or DO to provide clinical expertise to Utilization management/Medical Necessity Reviews, Benefit Determinations, Appeals and Grievances with respect to medical policies, protocols and product designs in accordance with regulatory bodies including NCQA, CMS and the DOH. This Physician participates in the review of medical necessity policies and recommends coverage status based on evidence-based literature. This involves working with external reviewing entities and clinical management and medical policy staff; ensuring that each level of review meets CMS and NCQA compliance; analyzing quality management/claims/utilization/provider contracting statistics; and working with our Pharmacists and Product Development teams to align our utilization goals with members’ needs. Qualified Physicians will be highly collaborative and able to mentor/advise our clinical management staff and others on rationale for policy stance and process efficiency surrounding several key initiatives including our Quality Management, Prior-Authorization, Concurrent Review, Medical Claim Review, Case management, Disease Management, Pharmacy Management and Health Education programs.
Candidates will be policy-driven and research orientated, with superior communication skills and operational skills in utilization management, QA and credentialing issues in a managed care medical environment. Must possess an MD or DO degree, current board certification, full and unrestricted Pennsylvania state licensure, and medical liability insurance (or eligibility to obtain). Five years of clinical experience will ideally include inpatient, outpatient, and QA experience, preferably with 3+ years in managed care or utilization review. Familiarity with Medicare requirements is also needed.
We offer a highly competitive, market-driven compensation/benefits plan. Capital BlueCross is also committed to providing physical activity and wellness opportunities for our employees. We offer a convenient on-site fitness center, wellness incentives, and access to personal fitness training sessions to help employees meet their health goals. We have been recognized as a 2016 Platinum-Level Fit-Friendly Worksite by the American Heart Association and were named #3 on Training Magazine’s list of the top 125 globally ranked training programs.
Our innovative Capital Blue Health and Wellness Centers located in Enola and Center Valley provide in-person service and inspiration to help people reach their health goals. Each one is open to the public and includes a fitness studio, Healthy You Café and on-site care guides skilled in multiple areas, including nutrition and biometrics screening. Capital BlueCross employees can take advantage of the many services offered at Capital Blue at little to no cost.
Capital BlueCross is an independent licensee of the BlueCross BlueShield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law. We offer a highly competitive, market-driven compensation/benefits plan. Engage with us on LinkedIn, Twitter, Facebook or Instagram. Interested and qualified candidates should apply to: Joe.McCloskey@capbluecross.com
**THE HIRED EMPLOYEE WILL NEED TO SIGN A NON-DISCLOSURE, NON-SOLICITATION, AND NON-COMPETITION AGREEMENT **
Internal Number: 11-575-918
About Capital BlueCross
Capital BlueCross is Central Pennsylvania’s largest health insurer, with a 21-county service area and more than 11,000 professional providers available to deliver care to our members.