Medical Director, Operations (CalPERS)
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: October 12, 2024
Job Description:
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, Operations - CalPERS will report
to the Vice President, Medical Management. In this role you will
deliver and collaborate on clinical review activities, which
includes management of the physician processes in support of
utilization management and transactional functions for CalPERS
membership. These functions include performance of pre-service,
concurrent and retrospective utilization review, Appeals and
Grievances, and provider claims dispute reviews. The Medical
Director, Operations - CalPERS facilitates performance management
and goals in alignment with organizational goals for the CalPERS
membership. Moreover, the Medical Director, Operations - CalPERS
leads or meaningfully contributes to the Blue Shield priorities and
transformative initiatives that continue to improve the health and
wellbeing of Blue Shield of California CalPERS members. You will
also provide direction and leadership in compliance with regulatory
requirements and key operational metrics and work collaboratively
with the Director, CalPERS Utilization Management to achieve these
goals. 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 while supporting clinical staff
in maintaining high quality clinical reviews and work products and
process improvement and optimization efforts for the CalPERS
membership as well as other lines of business, including
Medicare
- Partner closely with the Director, CalPERS Utilization
Management to develop improved utilization of effective and
appropriate services and support operational implementation of
transformation initiatives for the CalPERS membership
- Support Director, CalPERS Utilization Management in
coordinating the care of CalPERS membership, including partnering
with Included Health, to provide access to high-quality health care
to these members
- Serve as a clinical, regulatory and quality improvement
resource and clinical thought leader within the organization for
the CalPERS membership
- Support Vice President, Medical Director 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
- Understands and abides by all departmental policies and
procedures as well as the organization's Standards of Conduct and
Corporate Compliance Program
- Attends mandatory Corporate Compliance Program education
sessions, as required for this position, including the annual
mandatory Standards of Conduct class
- Participates actively assigned Committees
- Abides by all applicable laws and regulations as mandated by
state and federal laws
- Other duties as assigned 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 ABMS categories, preferably
Internal Medicine, required
- 5 years' experience in managed care that can contribute to
utilization management, case management, and/or quality improvement
activities or other health care administrative operations at the
IPA or health plan level preferred
- Knowledge of Medicare, California statutes and regulations
including DMHC and understanding of NCQA accreditation standards
preferred
- Knowledge and skilled application of National evidence-based
medical necessity criteria references (MCG or InterQual)
preferred
- Experience in data analysis and key performance indicators
(KPI's) to drive performance improvement preferred
- An ability to work independently to achieve objectives and
resolve issues in ambiguous circumstances
- Clear, compelling communication skills with demonstrated
ability to motivate, guide, influence, and lead others, including
the ability to translate detailed analytic analysis and complex
materials into compelling communications
- Strong collaboration skills to effectively work within a team
that may consist of diverse individuals who bring a variety of
different skills ranging from medical to project management and
more
- 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.
Keywords: Blue Shield of California, Fremont , Medical Director, Operations (CalPERS), Executive , Rancho Cordova, California
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