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El Dorado Hills

    Medical Director, Operations - El Dorado Hills, CA, United States - Blue Shield of California

    Blue Shield of California
    Blue Shield of California El Dorado Hills, CA, United States

    1 day ago

    Default job background
    Full time
    Description
    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.

    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.

    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
    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
    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; 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)
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