Medical Director, Operations (Medi-Cal)
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: October 12, 2024
Job Description:
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 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.
- 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.
Keywords: Blue Shield of California, Cupertino , Medical Director, Operations (Medi-Cal), Healthcare , Rancho Cordova, California
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