Accountable for activities and personnel related to Medical Policy, Clinical Policy and Utilization Management review. Provide strategic leadership and direction related to all aspects of medical policy, benefit interpretation, FAM updates and Plan education. This encompasses all functions related to delivering medical policy/benefit interpretation across all Plan products including Plan inquiries and subsequent education, FAM author of medical information/clarification/guidance and Plan inquiries and responses. Provides direction and leadership for multiple projects, services and associated deliverables of significant complexity and/or impact related to FEP Medical Policy/Benefit Delivery. Leads strategic cross-functional projects and teams developing project scope and requirements for proposed initiatives and Pilots, including outcome measures.

Responsibilities include but are not limited to:

• Provides strategic direction and clinical leadership in the development of all MCB departments including interpretation and implementation of appropriate medical/benefit policies and the Clinical Trials Unit for the Service Benefit Plan, Operations Center, Office of Personnel Management and National Programs.
• Leads strategic cross-functional projects/teams working with PMO to develop project scope and outcome measures, assuring that operational components are addressed to meet Plan business needs and execution while ensuring projects are aligned with FEP strategic direction.
• Scans business and healthcare environment to develop proactive and strategic action plans (operational and financial) to address FEP medical policy and Plan management needs on an individual and collective basis.
• Provides strategic direction for utilization management requirements to improve quality and lower cost for medical benefit products.
• Provides leadership and direction for medical policy on project-related issues at BCBSA and FEP conferences, internal and external meetings and in general communications with BCBS Plans.
• Prioritizes Pharmacy and Medical Policy Committee PMPC medical policy agenda topics. Coordinates with BCBSA Office of Clinical Affairs staff to disseminate PMPC SME feedback on the scientific literature and position statements to incorporate industry practice.

Required Basic Qualifications:

• A Bachelor’s degree in a clinical field from an accredited university
• Minimum of 10 years of healthcare experience
• Minimum of 7 years health policy administration
• Minimum requirement of 7 years supervisory experience
• Prior experience with a national managed care organization a plus
• Familiarity with the FEHBP helpful
• Prior project/team leadership and project management experience
• Specific in-depth and applied knowledge and understanding of medical policy, benefit design and interpretation, network development, contracting, maintenance, problem resolution, cost oversight and activity reporting.
• In-depth knowledge of integrating network activities with benefit design.

Preferred Basic Qualifications:

• Networks and Contracting
• Utilization Management
• Medical Policy
• Behavioral Health
• Benefit Design
• Graduate degree
• AHM
• Licensed in a clinical field by the appropriate board

Blue Cross Blue Shield Association is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, national origin, age, gender identity, disability, veteran status, genetic information or any other legally protected characteristics.