Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director of Medical Policy will report to the Vice President of Medical Management. In this role you will be accountable for working in partnership with other leaders to provide clinical support for all medical, medication, and payment policy initiatives. In addition, you will be the clinical driver for medical policy innovations, supporting medical payment operations, leading the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, and functioning as the in-house expert and trainer for staff related to medical, medication, and payment policy, pricing, and coding.

Your Work

In this role, you will:

• Provide clinical oversight, input, and support for Medical Policy operations. Chair the Medical Policy Committee.
• Provide medical support and input for the Blue Shield of California medication management process, including working closely with Pharmacy Services team to promote safe, effective, and cost-efficient pharmaceutical care for members. Chair the Pharmacy and Therapeutics Committee; provide medical expertise in daily clinical rounds for drug authorization case review.
• Provide medical support and input for the BSC Payment Policy committee, overseeing and advising about payment policies, claims editing code loads, and other clinical code editing issues; Chair the Payment Policy Committee.
• Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs (division of financial responsibilities).
• Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims.
• Consult with Blue Shield of California legal to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issues.
• Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives such as Coverage with Evidence Development, and the development of robust and efficient approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devices.
• Act as Blue Shield's representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy Panel.
• Participate on the California Technology Assessment Forum and other related activities.
• Partner with Network Management and Provider Partnership staff to resolve issues with Blue Shield providers related to clinical policy, coding, and billing.
• Facilitate IPA/MG and Provider education seminars regarding medical, medication and payment policy.

Your Knowledge and Experience

• A Medical degree (M.D./D.O.) and 12years' 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.
• Active Board Certification in one of ABMS categories, preferably Internal Medicine, required.
• Require Prior health plan experience - specifically with medical and medication policy development, technology assessment, and clinical coding preferred.
• Clinical work in a primary care discipline (Internal Medicine, Family Practice, Pediatrics) or General Surgery desired.
• Understanding of the California marketplace, including California health care laws and regulations desired.