Sr Medical Director (Town of Texas)

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve. Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, there's no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, you'll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

The Senior Medical Director, Utilization Management is the physician leader accountable for strategic and operational leadership of utilization management (UM) programs across commercial, ACA, and/or Medicare Advantage lines of business. This role provides enterprise-level clinical leadership to ensure UM programs improve quality, appropriateness of care, provider collaboration, and total cost of care, while meeting regulatory, accreditation, and compliance standards.

This position serves as the senior clinical authority for UM policy, decision-making, and performance, and leads other Medical Directors and clinical staff engaged in utilization review, prior authorization, and medical necessity determinations.

Candidates applying to this position may be hybrid or remote and can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas. The candidate selected for this role will be required to visit the Omaha based job site for occasional strategic meetings throughout the year.

Key Responsibilities

Strategic & Clinical Leadership

• Provide clinical leadership for utilization management programs, including prior authorization, concurrent review, retrospective review, and appeals.

• Set UM strategy aligned with organizational goals for affordability, quality, member experience, and regulatory compliance.

• Serve as senior clinical advisor to executive leadership on utilization trends, risk areas, and intervention opportunities.

• Oversee the medical policy team, development and refinement of utilization management policies, protocols, and criteria based on nationally recognized standards (e.g., MCG, InterQual).

• Lead the Medical Policy and Utilization Management Governance Committees.

Medical Decision-Making & Oversight

• Oversee complex and high-risk utilization review cases, including medical necessity determinations and claim reviews.

• Conduct clinical reviews and/or oversee peer-to-peer reviews with ordering and attending providers.

• Ensure consistent, evidence-based application of clinical guidelines and medical policy across all UM functions.

• Provide clinical expertise to teams conducting coding, payment integrity, and reimbursement activities.

• Contribute medical expertise to case management and care coordination processes, ensuring members transition to the appropriate level of care.

Provider & Stakeholder Engagement

• Act as senior clinical UM liaison to network providers, facilities, and delegated UM partners.

• Build and maintain strong physician relationships to support appropriate utilization, practice transformation, and quality improvement.

• Represent Medical Management in cross-functional leadership forums (Quality, Network, Pharmacy, Population Health).

Program Performance & Improvement

• Lead development and implementation of UM interventions that reduce unnecessary utilization while maintaining or improving quality outcomes, including strategies for integration of AI technologies to improve efficiency, accuracy of reviews, and user experience.

• Review utilization data, denial patterns, appeals outcomes, and inter-rater reliability results to identify improvement opportunities and develop solutions for implementation and continuous quality improvement.

• Oversee performance and outcomes generated by contracted UM vendors.

• Ensure UM programs meet CMS, URAC, and state regulatory requirements.

• Support workforce development, consistency of decision-making, and clinical calibration across UM teams.

• Conduct and support training of medical directors and UM staff.

Required Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO).

• Board Certified by an American Board of Medical Specialties (ABMS) board.

• Preferred current, unrestricted medical license in Nebraska. If not currently actively licensed in Nebraska, verification of attainment within 6 months of start.

• 10+ years of combined clinical practice and health care industry experience.

• Demonstrated experience in utilization management, medical necessity review, and physician peer review.

• Demonstrated effective communication skills, a commitment to continuous improvement in healthcare delivery, and the ability to adapt to a dynamic and rapidly evolving healthcare environment.

Preferred Qualifications

• Prior experience in a senior or enterprise-level UM leadership role.

• Three + years Managed care experience across Commercial and/or Medicare Advantage populations.

• Experience leading or overseeing other Medical Directors.

• Strong background in quality improvement, population health, and cost containment initiatives.

Additional Qualifications

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Other duties may be assigned.

• The ability to meet or exceed the attendance and timeliness requirements of their departments.

• The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

Equal Opportunity Statement

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.