Your Role

The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and retrospective provider claims dispute reviews. Additional functions will include leading Concurrent Review and SNF/LTC rounds as well as Interdisciplinary Care rounds. The Lead Medical Director facilitates performance management of team and sets team goals in alignment with organizational goals. The Medical Director, Operations (Lead) will report to the VP, Medical Management.

Moreover, the medical director leads or meaningfully contributes to the BSC/BSCPHP priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California Promise Health Plan members. The Lead Medical Director serves as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization and externally with provider group and community partners. They are 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 (pre service requests, Appeals and Grievances, Provider Claims Disputes, pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts
• Deliver clinical leadership by holding Concurrent Review and SNF/LTC rounds as assigned and facilitating Interdisciplinary Care Rounds as part of Care Management, supports Case Management
• Drives care coordination and case management functions for Palliative Care and Population Health Management by leading clinical initiatives as assigned and serving as a clinical, regulatory and quality improvement resource, clinical thought leader within the organization and externally with provider groups and community partners
• Serves as strategic support to the VP, Medical Director - Medical Management and Promise CMO with strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver. The lead may collaborate with teams in the implementation and operation of assigned initiatives
• Drive regulatory compliance through their knowledge of Medi-Cal and Medicare benefits and available resources
• Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class. The lead will abide by all applicable laws and regulations as mandated by state and federal laws
• Participate actively assigned Committees
  

Your knowledge and Experience

• A Medical degree (M.D./D.O.) and 12 years' experience, including a minimum of 5 years' experience in active clinical practice in an adult-based primary care specialty (Internal Medicine or Family Practice) is required
• Unrestricted California State Medical License required
• Board Certification in one of American Board of Medical Specialties categories, preferably Internal Medicine, required
• Knowledge of/experience working in a Health Plan setting preferred
• Knowledge of Medi-Cal, Medicare, California statutes and regulations including DMHC, DHCS preferred
• Understanding of NCQA accreditation standards preferred
• Experience managing or arranging care for patients with behavioral and medical comorbidities as well as an understanding of social drivers of health, including programs available through health plans, counties and the state for support preferred
• Ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Understanding overall managed care organization, business strategies and financial metrics
• Listening, interpreting, negotiating and consensus building in bringing business conflicts to successful resolution

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.

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