Your Role

The Medical Director provides clinical leadership within the Office of the CMO for Blue Shield Promise Health Plan, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of preservice, concurrent, retrospective utilization review, Appeals and Grievances, and retrospective provider claims dispute reviews. Moreover, the medical director leads or meaningfully contributes to the Office of the CMO priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California Promise Health Plan members. The medical director serves as a role model for other clinical staff and is a knowledgeable resource in Medi-Cal and Medicare regulatory requirements, NCQA guidelines, and measurement of health care quality (HEDIS and CAHPS). The Blue Shield Promise Medical Director works collaboratively with Medical Care Services (MCS) and other appropriate departments across product lines to identify and address opportunities to improve service, reduce administrative cost and support department and organizational business goals. The medical director will be responsible for engaging in organization wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization, and contracted provider partners in each regional market.

Your Work

In this role, you will:

• Complete assigned clinical reviews (preservice requests, Appeals and Grievances, Provider Claims Disputes, pharmacy, or others) within compliance standards
• Support clinical staff in maintaining high quality clinical reviews and work products
• Support in process improvement and optimization efforts
• Leads Concurrent Review and SNF/LTC rounds as assigned
• Facilitates interdisciplinary Care Rounds as part of Care Management
• Lead clinical initiatives as assigned
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization and externally with provider group and community partners
• Support Chief Medical Officer and VP, Medical Director - Medical Management, in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Knowledge of Medicare and Medi-Cal benefits and available resources
• Understands and abides by all department policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program
• Knowledge of Medicare and Medi-Cal benefits and available resources
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Actively participates in assigned committees
• Abides by all applicable laws and regulations as mandated by state and federal laws

Your knowledge and Experience

• Deep experience working with Medi-Cal and/or Medicare populations
• 5-10 years' experience, including a minimum of 5 years' experience in managed care is required that can contribute to utilization management, case management, or other health care administrative operations at the IPA or health plan level
• Knowledge of/experience working in a Health Plan setting is preferred
• Knowledge of Medicare, Medi-Cal, NCQA guidelines is preferred
• Considerable knowledge of a wide range of behavioral an psychosocial problems and their diagnosis and treatment
• Ability to express ideas clearly and concisely and execute work effectively
• Excellent communication skills both orally and in writing
• Medical Degree (MD) or Doctor of Osteopathic Medicine (DO) from an accredited medical school
• Physician licensed by the State of California, active and unrestricted
• Board certification in an American Board of Medical Specialties recognized specialty or subspecialty
• Knowledge of the wide ranges of psychosocial challenges, social determinants and health care inequities in diverse communities\
• Knowledge and skilled application of National evidenced-based medical necessity criteria refences (MCG or Interqual)
• Excellent written and verbal communications skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Pay Range:

The pay range for this role is: $ 155331.00 to $ 325743.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.