Program Integrity Director Jobs in Rhode Island (NOW HIRING)

Summary
 Why should you join the BlueCross BlueShield of South Carolina family of companies?
Other companies come and go, but we've 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 nation's 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:
The Behavioral Health Medical Director provides medical leadership to specific health plan or LOB to include overseeing physician review, utilization review/quality assurance, directing case management, developing and implementing medical policies and standards, evaluating new technologies and treatments. In this role, you will identify trends in medical management and proactively aid in setting direction to improve these.
The Behavior Health Medical Director that we seek will have extensive experience in the following areas:
STRATEGIC AND CLINICAL LEADERSHIP
The Medical Director provides clinical oversight for all behavioral health activities across utilization management, care coordination, quality, and population health for South Carolina Medicaid. The role ensures Healthy Blue's BH strategy aligns with SCDHHS priorities, providing clinical authority to direct program strategy, oversee clinical policies, and support statewide goals such as improved transitions of care and reduced emergency department dependence.
UTILIZATION AND COST MANAGEMENT
The BH Physician Reviewer ensures defensible, evidence based utilization decisions; provides clinical review for complex and high cost cases; and partners with internal program integrity teams to identify inappropriate utilization patterns. This role directly impacts Healthy Blue's cost of care performance while maintaining member safety and compliance with SCDHHS expectations for medically necessary, least restrictive care.
MEMBER SAFETY, INTEGRATED CARE, AND HEALTH EQUITY
This position provides clinical leadership for integrated BH/medical models, supports suicide prevention and crisis response initiatives, and oversees transitions-of-care strategies to reduce readmissions and adverse events. The role advances health equity by promoting culturally responsive care and addressing disparities across South Carolina's rural and urban regions.
Description
 

Location:This position is full-time (40-hours/week) Monday-Friday REMOTE in South Carolina. You will be required to come on-site to the 4101 Percival Road, Columbia, SC 29229 location twice monthly.

Sponsorship: This position is not eligible for sponsorship now or in the future.

What You'll Do:

• Provides leadership and medical support on medical and regulatory matters. Identifies trends in medical and pharmacy costs, utilization trends, and proactively makes recommendations and initiates solutions to impact these.

• Provides leadership to clinical team and operations in order to increase compliance, improve efficiency, and increase communication. Acts as resource for providers, staff, part time medical reviewers, and as requested, customers, on issues concerning medical policies and regulations.

• Provides clinical support to Payment Integrity Unit(s) to analyze abuse patterns and recommend solutions.

• Provides oversight and leadership with quality improvement and health plan and medical program accreditation(s).

• Works with staff and other leadership in developing ideas related to quality initiatives, good clinical support, and outreach to the network.

• Responsible for physician review (UM, Appeals, CM) - reviews physician and provider practice pattern analysis and other statistical data.

• Conducts research into new or controversial medical procedures and technology.

• Educates staff, network providers, and medical community on various aspects of medical policy and program administration.

To Qualify for This Position, You'll Need the Following:

• Required Education: Doctorate Degree - Medical Doctor (MD) with current active medical license, without restriction. If Behavioral Health, Medical Director - Doctor of Psychiatry with current active medical license, without restriction.

• Required Work Experience:
  o 8 years post graduate experience in direct patient care.

• Required Skills and Abilities:

• o Managed care knowledge and experience required.
  o Working knowledge of regulatory and accreditation entities, i.e., URAC, NCQA, DOI, and DOL standards.
  o Excellent verbal and written communication skills.
  o Excellent customer service, organizational, and presentation skills.
  o Good judgment skills.
  o Proficiency in spelling, punctuation, and grammar.
  o Ability to persuade, negotiate, or influence others, represent our company well.
  o Ability to work as a team member as well as a leader.

• Required License and Certificates: Active, unrestricted medical license from the United States and in the state of hire and current board certification in a recognized specialty.

We Prefer That You HaveTheFollowing:

• Doctorate Degree - Medical Doctor (MD) with current active South Carolina medical license, without restriction.

• Completion of a Psychiatry residency with preference for specialty in Child and Adolescent Psychiatry.

• Strong knowledge of Medicaid programs, regulations and compliance.

• Ability to develop and maintain positive relationships with peers, enterprise, customers, and partners.

• Demonstrated ability to drive continuous improvement and cost reduction.

• Ability to effectively collaborate with cross-functional teams.

• Executive level presentation skills.

• Experience working with the SC Department of Health and Human Services.

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.

Management will be conducting interviews with those candidates who are the most qualified, with prioritization given to those candidates who demonstrate the required qualifications.

Pay Range Information:

Range Minimum
$206,011.00

Range Midpoint
$309,767.00

Range Maximum
$413,523.00

Pay Transparency Statement:

Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

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 mycareer.help@bcbssc.comor call 800-288-2227, 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. Here's moreinformation.

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