Medical Director, Operations (Lead)
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: October 12, 2024
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:
- 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.
Keywords: Blue Shield of California, Fremont , Medical Director, Operations (Lead), Executive , Rancho Cordova, California
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