Senior Medical Director - CBU

About this role

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

About the Role

The Senior Medical Director supporting the Commercial Business Unit (CBU) serves as the primary physician leader and clinical liaison for CBU clinical engagements. The role provides clinical credibility, timely medical expertise, and actionable recommendations that help make healthcare work for CBU’s customers while strengthening relationships, supporting client retention and growth, and translating complex clinical topics into practical, client-ready discussions. What You'll Do

Client and Market-Facing Clinical Leadership  • Serve as the Medical Director attendee and presenter for the Board, annual and biannual performance meetings with Horizon’s CBU customers, including national account and ASO clients.  • Participate in finalist, broker, prospective clients, existing customers and internal account team preparation and presentations.  • Build and maintain productive relationships with external Medical Directors representing CBU customers, clinical teams working for brokers and consultants, and NJ DOBI contacts on clinical issues.  • Use client profiles and account background materials to tailor clinical discussion, anticipate questions, and present complex clinical information in a clear, client-friendly manner.  • Attend customer status calls with Account Managers or Account Executives when clinical expertise is needed. 

Clinical Escalations, Appeals and Performance Guarantees  • Provide clinical expertise on escalated customer inquiries and appeals, supporting the committed three-business-day turnaround expectation for clinical escalations. 

• Speak directly with network providers, as appropriate, to address authorization-related escalations in support of CBU’s customers. 

• Provide clinical expertise related to audits and performance guarantees. 

Medical Policy, Coding and Cost Optimization  • Act as the liaison between the Medical Policy Committee and the CBU teams on medical policy changes that could impact CBU clients.  • Bring medical policy-related concerns voiced by CBU clients to the appropriate committee or forum for review and resolution.  • Support clinical coding updates and coding changes requested by, or impacting, CBU clients.  • Develop, participate in and communicate medical cost optimization programs that impact CBU clients.  • Provide recommendations for internal process updates based on customer feedback and recurring clinical issues. 

Cross-Functional Resource Planning and Meeting Support  • Partner with CBU Account Executives, Pharmacy, Analytics, Care Management, and administrative support to coordinate annual wrap-up, finalist and client-facing meeting support.  • Coordinate with Analytics on outcomes reporting needed for client meetings.  • Partner with Nurse Case Managers to complete interdisciplinary rounds for clients’ with performance guarantees related to case management activity.  

Program, Audit and Vendor Support  • Participate in and provide support for clinical audits of Horizon Care Navigator, Care Management Plus, High-Cost Claimant and related programs.  • Work closely with Horizon Care Navigator, Horizon Care Management Plus and Pharmacy teams to provide clinical insight on cases.  • Clinically vet vendors requested by, or offered to, clients and provide recommendations on suitability, clinical value and alignment with client needs.  • Hold accountability for budget management of specialty match spend on utilization management reviews for clients.  • Participate in association and consortium workgroups related to medical policy, quality, cost containment, population health and sales, as applicable. 

What You Bring

Education/Experience:

• MD or DO degree with active, unrestricted medical license; board certification is strongly preferred.  • Requires a minimum 5 years of clinical practice experience. • Requires 3 years experience in managed care. • Experience with account management, sales, analytics, pharmacy, utilization or care management, medical policy, broker/consultant, or regulatory-facing teams is preferred.  • Strong executive presence and communication skills, with ability to represent Horizon in client, finalist, broker, consultant and external Medical Director discussions.  • Understanding of client needs, performance guarantees, clinical escalations, medical cost trends, high-cost claimant dynamics, utilization management and vendor evaluation preferred. 

Additional licensing, certifications, registrations:

• Requires American Board of Medical Specialties (ABMS) board certification.

Knowledge:

• Significant clinical leadership experience in managed care, health plan, payer, employer group, population health or related healthcare environment.  • Demonstrated ability to communicate complex clinical, utilization management, medical policy, pharmacy and cost containment topics to non-clinical audiences.  • Requires proficiency working with a Windows based environment including MS Office products. • Requires knowledge of clinical operations within a managed care organization. • Requires knowledge of Commercial health insurance products

Skills and Abilities: • Clinical judgment and credibility  • Client-centric communication and relationship management  • Enterprise collaboration and cross-functional influence  • Strategic thinking with practical execution discip

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