Director, Medicare
12 hours ago
Your Role
Reporting to the Sr. Director, Utilization Management, the role of the Director, Medicare & Medi-Cal Utilization Management is critical to the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives. This individual will play a key role as part of the Utilization Management team in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership. The Director, Medicare & Medi-Cal Utilization Management role will also provide direction and leadership in compliance to regulatory requirements and key operational metrics.
Your Work
In this role, you will:
- Manages and monitors prior authorization and concurrent review to ensure that the patient is getting the right care in a timely and cost-effective way.
- Leading development of UM strategy by leveraging the use of data/analytics to inform and technology solutions to streamline operational efficiencies while also building a cost-benefit methodology to rationalize decisions on UM reviews to be performed based upon staffing costs, productivity, and projected medical cost savings.
- Provides analysis and reports of significant utilization trends, patterns, and resource allocation. Partners with physicians and others to develop improved utilization of effective and appropriate services.
- Establishing and measuring productivity metrics to support workforce planning methodology and rationalization of services required to perform UM reviews.
- Reviewing and reporting out on Utilization Review (UR) trending for Medicare and Medi-Cal membership.
- Ensuring alignment of the authorization strategy with clinical policy, payment integrity, and network development strategies to optimize quality and cost of care.
- Responsible for managing strategic projects and supporting operations initiatives.
- Leading operational implementation of transformation changes (organizational management, process implementation, technology adoption).
- Responsible for operational teams' performance, resource management, continuous improvement, and training.
- Responsible for operational audit readiness, ensuring adequate processes and internal audit measures in place and maintained quarterly.
- Ensuring all operational processes are meeting regulatory and accreditation requirements.
- Fosters a culture of process excellence, BSC leadership principles, and a great place to work environment.
- Occasional business travel required.
Your Knowledge and Experience
- Requires current CA RN License
- Bachelor’s of Science in Nursing or advanced degree preferred
- Master’s degree or equivalent experience preferred
- Minimum of 10 years of Utilization Management or relevant experience, including 6 years of management experience
- Minimum of 5 years of progressive leadership in Utilization Management operations
- Health plan or similar health care organization structure experience required
- Successful track record in driving organizational change management
- Excellent relationship and consensus-building skills required
Pay Range:
The pay range for this role is: $ 165990.00 to $ 248930.00 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
-
Director, Medicare
19 hours ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role Reporting to the Sr. Director, Utilization Management, the role of the Director, Medicare & Medi-Cal Utilization Management is critical to the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives. This individual will play a key role as part of the Utilization Management team in...
-
Director of Medicare Services
1 month ago
Rancho Cucamonga, California, United States Inland Empire Health Plan Full timeAbout the RoleInland Empire Health Plan (IEHP) is seeking a highly skilled and experienced professional to fill the position of Manager of Medicare Administration. This role will play a critical part in leading the development, implementation, and maintenance of operational policies and strategies that support Medicare Advantage (MA) supplemental...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of...
-
Medical Director, Operations
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of...
-
Medical Director, Operations
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of...
-
Medical Director Operations
1 week ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly skilled Medical Director to join our team at Blue Shield of California. As a key member of our Medical Management department, you will play a critical role in ensuring our members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesDevelop and deploy medical management...
-
Medical Director Operations
2 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a highly skilled Medical Director, Operations to join our team at Blue Shield of California. As a key member of our Medical Management department, you will play a critical role in ensuring our members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesReview and make determinations...
-
Medical Director, Operations
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timep>The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on clinical...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on...
-
Medical Director Operations
1 week ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Medical Director Operations - CalPERS will play a pivotal role in ensuring Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. Reporting to the Vice President Medical Management, this position will deliver and collaborate on clinical review activities, including...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on...
-
Medical Director, Operations
1 month ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on...
-
Medical Director, Operations
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
-
Medical Director Operations Lead
1 week ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a highly skilled Medical Director, Operations Lead to join our team at Blue Shield of California. This is a critical leadership role that requires a strong clinical background, excellent communication skills, and the ability to drive strategic initiatives.Key ResponsibilitiesProvide clinical leadership and oversight to our Medical...
-
Medical Director, Operations Lead
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director, Operations Lead provides clinical leadership within the Blue Shield of California Medical Management department for all clinical review activities. This includes management of physician processes in support of utilization management and transactional functions. These functions include performance of pre-service, concurrent...
-
Medical Director, Operations
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe 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...
-
Medical Director, Operations
3 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
-
Medical Director, Operations
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour 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...
