- Be the medical decision-maker and support for the prior authorization registered nurse (RN) team, facilitating appropriate use of resources, including safe and timely decisions. These duties will require telephonic physician-to-physician discussions regarding current patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers
- The Medical Director will review pre- and post-service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy as well as legal and regulatory requirements. The Medical Director must be well-versed in most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency
- The Medical Director will participate in projects and committees as necessary
- Conduct problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions
- Work independently to achieve objectives and resolve issues in ambiguous circumstances
- Possess 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
- Work in high-pressure situations while maintaining good leadership and reasoning ability
- Demonstrate strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers
- Possess essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution
- Understand overall managed care organization, business strategies, and financial metrics; strong interpersonal and communication skills are needed to effectively interact with employees and clients in a professional and tactful manner
- Lead and provide training and guidance to others
- A minimum of 5 year's experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required
- A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting
- A medical degree (MD or DO) with five or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review
- Unrestrictive license to practice medicine in the State of California
- Board certified in a in a recognized medical or surgical specialty (preferably Internal Medicine)
-
Director of Operations
1 week ago
Nor-Cal Controls ES El Dorado Hills, United StatesNor-Cal Controls ES, Inc. has been a leader in SCADA and controls solutions for the renewable energy industry since 2006. Recognized as a top integrator in utility-scale power generation and energy storage, Nor-Cal Controls maintains high-quality engineering standards for all our ...
-
Director of Operations
2 weeks ago
V3 Electric El Dorado Hills, United StatesJob Title: Director of Operations · Annual Salary: $150K-200K · *This position requires In-Office Work/Remote Work is not an option. · About Us: · At V3, we have a young, hungry spirit to work hard and do what is right. We are disrupting the energy industry, and that is our drivi ...
-
Director of Operations
2 weeks ago
Nor-Cal Controls ES, Inc. El Dorado Hills, United StatesJob Description · Job DescriptionSalary: $150,000 - $185,000 · Nor-Cal Controls ES, Inc. has been a leader in SCADA and controls solutions for the renewable energy industry since 2006. Recognized as a top integrator in utility-scale power generation and energy storage, Nor-Cal Co ...
-
Director of Operations
2 weeks ago
V3 Electric El Dorado Hills, United StatesJob Title: Director of Operations · Annual Salary: $150K-200K · *This position requires In-Office Work/Remote Work is not an option. · About Us: · At V3, we have a young, hungry spirit to work hard and do what is right. We are disrupting the energy industry, and that is our drivi ...
-
Medical Director, Operations
2 weeks ago
Blue Shield of California El Dorado Hills, CA, United States Full timeThe Medical Director, Commercial is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of pre and post service utilization review, and collaborat ...
-
Medical Director, Operations
2 weeks ago
Blue Shield of California el dorado hills, United Statesp> Your Role The Medical Director, Commercial is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of pre and post service utilization review, ...
-
Director of Operations
4 days ago
Nor-Cal Controls ES, Inc. El Dorado Hills, United StatesAbout the Director of Operations: · The Director of Operations will oversee the company's day-to-day activities, ensuring the organization is managed and performs at peak efficiency. This role will direct and support multiple teams to ensure the success of the company's mission a ...
-
Director of Clinical Operations
2 weeks ago
EP, LP Folsom, United StatesOur medical practice, known for its exceptional mission-driven, patient-centric culture, is actively seeking a Director of Clinical Operations to play a hands-on role in supporting the Providers and Staff and the planned growth of the business. The role will be essential to estab ...
-
Operations Director
3 weeks ago
Essel Roseville, United StatesJob Description · Job DescriptionOperations Director – Job Description Classification: Exempt, Full-Time Compensation Structure: · • · Base salary with discretionary increases dependent on metrics / performance · • Job-Level Bonus Potential o Bonus based on attainment of mutual ...
-
Director of Operations
1 week ago
Nor-Cal Controls ES Shingle Springs, United StatesJob Description · Job Description Salary: $150,000 - $185,000 · Nor-Cal Controls ES, Inc. has been a leader in SCADA and controls solutions for the renewable energy industry since 2006. Recognized as a top integrator in utility-scale power generation and energy storage, Nor-Cal ...
-
Regional Director of Operations
2 hours ago
Smash Park Entertainment Group Roseville, United StatesSmash Park, a leading eatertainment brand, is seeking an experienced and dynamic Regional Director of Operations to join our team. · What we do: We Deliver Fun. · Who we are: We are passionate, thoughtful, and competitive professionals who are obsessed with serving others. · Wha ...
-
FI Operations Director
1 week ago
Gainwell Technologies LLC Roseville, United StatesGreat companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. You'll have an incredible opportunity to grow your career in a company that values your cont ...
-
FI Operations Director
5 days ago
Gainwell Technologies Roseville, United StatesGreat companies need great teams to propel their operations. Join the group that solves business challenges and enhances the way we work and grow. Working at Gainwell carries its rewards. Youll have an incredible opportunity to grow your career in a company that values your contr ...
-
Director of Operations
3 weeks ago
V3 Electric Folsom, United StatesJob Title: Director of Operations · Annual Salary: $150K-200K · This position requires In-Office Work/Remote Work is not an option. · About Us: · At V3, we have a young, hungry spirit to work hard and do what is right. We are disrupting the energy industry, and that is our dr ...
-
Director of Operations
3 weeks ago
Essel Environmental Sacramento, United StatesEssel Environmental is partnered with an established Civil Engineering and Land Survey Consulting Firm here in Sacramento that is searching for an Operations Director must have the drive and discipline to monitor, maintain and enforce existing department policies and procedures, ...
-
Director of Operations
5 days ago
Starwest Botanicals, Inc. Sacramento, United StatesDirector of Operations · Role Summary · Starwest Botanicals is an industry leader in the herb, botanicals, spice, and tea industry. Located in Sacramento, California, Starwest has grown to become a global player in the organic and better-for-you space. With nearly 50 years of exp ...
-
Executive Director of Operations
2 weeks ago
Workstream Roseville, United StatesOverview: · This position is accountable for the daily restaurant operations at both stores while · managing the Operational team. · Reports to: · Managing Director · Direct Reports: · Senior Director of Operations (Roseville), Senior Director of Operations (Arden · Hills), Se ...
-
Operations Director
3 weeks ago
Essel Roseville, California, United States PermanentOperations Director – Job Description Classification: Exempt, Full-Time Compensation Structure: · • · Base salary with discretionary increases dependent on metrics / performance · • Job-Level Bonus Potential o Bonus based on attainment of mutually agreed upon, annually establis ...
-
Operations Director
1 week ago
Essel Environmental Consulting Roseville, United StatesEssel Environmental · is partnered with an established · Civil Engineering · and · Land Survey · Consulting Firm here in · Sacramento · that is searching for an · Operations Director · must have the drive and discipline to monitor, maintain and enforce existing departmen ...
-
Operations Director
1 week ago
Industrial Pro Recruiting Roseville, United StatesOperations Director – Job Description · Classification: · Exempt, Full-Time · Compensation Structure: · Base salary with · discretionary · increases dependent on metrics / performance · Job-Level Bonus Potential · Bonus based on attainment of mutually agreed upon, annually es ...
Medical Director, Operations - El Dorado Hills, United States - Blue Shield of California
Description
Your Role
The Medical Director, Commercial is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of pre and post service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Medical Director of Medical Operations.
Your Work
In this role, you will:
Your Knowledge and Experience
Pay Range:
The pay range for this role is: $ 155,331.00 to $ 325,743.00 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.
