MEDICAL DIRECTOR, OPERATIONS (LEAD)
Company: Blue Shield of CA
Location: El Dorado Hills
Posted on: October 11, 2024
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Job Description:
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:
Your knowledge and Experience
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. #LI-SS8
Keywords: Blue Shield of CA, Fremont , MEDICAL DIRECTOR, OPERATIONS (LEAD), Executive , El Dorado Hills, California
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