Medical Director, Operations
7 days ago
p>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 review activities, which includes management of the physician processes in support of utilization management and transactional functions for CalPERS membership. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.The Medical Director, Operations - CalPERS facilitates performance management and goals in alignment with organizational goals for the CalPERS membership. Moreover, the Medical Director, Operations - CalPERS leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California CalPERS members. You will also provide direction and leadership in compliance with regulatory requirements and key operational metrics and work collaboratively with the Director, CalPERS Utilization Management to achieve these goals.Complete assigned clinical reviews (preservice requests, Appeals and Grievances, Provider Claims Disputes, pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for the CalPERS membership as well as other lines of business, including Medicare
Partner closely with the Director, CalPERS Utilization Management to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the CalPERS membership
Support Director, CalPERS Utilization Management in coordinating the care of CalPERS membership, including partnering with Included Health, to provide access to high-quality health care to these members
Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization for the CalPERS membership
Support Vice President, Medical Director 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
Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
A Medical degree (M.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
5 years’ experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level preferred
Knowledge of Medicare, California statutes and regulations including DMHC and understanding of NCQA accreditation standards preferred
Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual) preferred
Experience in data analysis and key performance indicators (KPI’s) to drive performance improvement preferred
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
Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
Excellent analytical, time management and organizational skills
Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint
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Medical Director Operations
4 days 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...
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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...
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Medical Director Operations
6 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a highly skilled Medical Director to lead our CalPERS operations team. As a key member of our Medical Management team, you will be responsible for delivering and collaborating on clinical review activities, including management of physician processes in support of utilization management and transactional functions for CalPERS...
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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...
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Medical Director, Operations
4 weeks 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...
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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...
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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...
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Medical Director, Operations
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeJob DescriptionYour 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...
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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...
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Medical Director, Operations
4 weeks 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...
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Medical Director, Operations
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director, Operations - CalPERS will play a pivotal role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management, and will be responsible for delivering and collaborating on...
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Medical Director Operations
6 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob Title: Medical Director, OperationsBlue Shield of California is seeking a highly skilled Medical Director, Operations to join our team. As a key member of our Medical Management team, you will play a critical role in ensuring that our organization is at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based...
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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...
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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...
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Medical Director, Operations
4 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeJob DescriptionYour 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...
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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...
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Medical Director Operations
4 days 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...
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Medical Director Operations
18 hours 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 team, you will play a critical role in ensuring that our organization is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system...
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Medical Director, Operations
1 month 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...
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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...
