- Complete assigned clinical reviews (preservice requests, Appeals and Grievances, Provider Claims Disputes, pharmacy, or others) within compliance standards
- Support clinical staff in maintaining high quality clinical reviews and work products
- Support in process improvement and optimization efforts
- Leads Concurrent Review and SNF/LTC rounds as assigned
- Facilitates interdisciplinary Care Rounds as part of Care Management
- Lead clinical initiatives as assigned
- Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization and externally with provider group and community partners
- Support Chief Medical Officer and VP, Medical Director - Medical Management, 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
- Knowledge of Medicare and Medi-Cal benefits and available resources
- Understands and abides by all department policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program
- Knowledge of Medicare and Medi-Cal benefits and available resources
- Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
- Actively participates in assigned committees
- Abides by all applicable laws and regulations as mandated by state and federal laws
- Deep experience working with Medi-Cal and/or Medicare populations
- 5-10 years' experience, including a minimum of 5 years' experience in managed care is required that can contribute to utilization management, case management, or other health care administrative operations at the IPA or health plan level
- Knowledge of/experience working in a Health Plan setting is preferred
- Knowledge of Medicare, Medi-Cal, NCQA guidelines is preferred
- Considerable knowledge of a wide range of behavioral an psychosocial problems and their diagnosis and treatment
- Ability to express ideas clearly and concisely and execute work effectively
- Excellent communication skills both orally and in writing
- Medical Degree (MD) or Doctor of Osteopathic Medicine (DO) from an accredited medical school
- Physician licensed by the State of California, active and unrestricted
- Board certification in an American Board of Medical Specialties recognized specialty or subspecialty
- Knowledge of the wide ranges of psychosocial challenges, social determinants and health care inequities in diverse communities
- Knowledge and skilled application of National evidenced-based medical necessity criteria refences (MCG or Interqual)
- Excellent written and verbal communications skills
- Excellent analytical, time management and organizational skills
- Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint
- Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
- Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
- Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
- Hybrid - In a business unit approved office a few times per year to 3 days per week, on average
- Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.
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Medical Director, Operations - Rancho Cordova, United States - Blue Shield Of California
Description
Job DescriptionYour Role
The Medical Director provides clinical leadership within the Office of the CMO for Blue Shield Promise Health Plan, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of preservice, concurrent, retrospective utilization review, Appeals and Grievances, and retrospective provider claims dispute reviews. Moreover, the medical director leads or meaningfully contributes to the Office of the CMO priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California Promise Health Plan members. The medical director serves as a role model for other clinical staff and is 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
The pay range for this role is: $ to $ 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.
About the Team
Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us
Our Values:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
