Your Role
The BSC/BSC Promise Health Plan (BSCPHP) Medical Management department is focused on ensuring our members get the right level of care, at the right time, and at the right cost.We do this by developing and deploying medical management capabilities that are aligned with industry best practices. This minimizes the impact of cost of healthcare and improved operational efficiency.Consistent with Blue Shield's values, the Medical Management department will deliver best-in-class health care management through the following: Maintain a focus on the care and service our members receive while exercising fiscal responsibility. Forge partnerships to ensure a collaborative approach to our members' care, resulting in improved healthcare outcomes. Build a foundation and infrastructure that leverages technology and supports innovative solutions. Promote a work culture that encourages teamwork and rewards exceptional performance while striving for continuous improvement.
The Medical Director, Operations functions as a key member of the BSC Promise utilization management review team. The Medical Director, Operations will report to the VP, Medical Management or their designee.
The Medical Director reviews and makes determinations regarding all member and provider requests for service including prior authorization, concurrent reviews, retrospective reviews, appeals, grievance resolution, provider disputes. The Medical Director will determine the medical necessity of requests or appeals for coverage of medications (oral and injectable), laboratory tests, office visits and consultations, procedures, surgeries, level of care, continuity of care, durable medical equipment (DME), and any other service that is based on medical necessity or that can be considered investigational. The Medical Director will evaluate appeals for the Blue Shield Promise Health Plan Medi-Cal lines of businesses. The Medical Director will be available to support Case Management, Population Health Management, and interdisciplinary care team rounds.
Your Work
In this role, you will:
Ability to combine a thorough knowledge of BSCPHP medical and pharmacy policy, state and federal laws and regulations, and network design; with excellent clinical experience and rational decision making in order to make fair and consistent determinations for BSC members.Be available to the Clinical Quality Review Department to review member quality of care grievances to determine if there were quality-of-care issue.Be available for peer-to-peer discussions with providers and Medical Directors from independent provider associations (IPA) and medical groups (MG) to reach consensus on issues relating to the care of BSC members.Work with other BSCPHP staff and will provide clinical expertise to other key BSCPHP divisions including Pharmacy Services, the BSCPHP Medical Policy Department, and the Law Department.Adjudicate member reviews in an efficient and timely manner that complies with all regulatory requirements while working effectively with nursing and coordinator staff.Communicates any educational or corrective action plans to address identified quality concerns.Strong decision-making, organizational, planning, and problem-solving skills, as well as strong interpersonal and communication skills are needed to effectively interact with staff, team members and others in a professional and tactful manner.Your Knowledge and ExperienceA 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.More than one year of experience working for a Health Plan making medical or quality of care decisions or more than three years’ experience working for a Medical Group, IPA, or Health Plan with relevant experience such as Credentialing Committee, Peer Review Committee, Utilization Management decision making or Regional Medical Director engaging IPA/MG leadership is preferred.Experience in Medicare or Medi-Cal benefits, policies, and managing Medi-Cal or Medicare patients in practice is 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.Strong decision-making, organizational, planning and problem-solving skills, as well as strong interpersonal and communication skills are needed to effectively interact with staff, team members and others in a professional and tactful manner. 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.#LI-SS8