Medical Director Operations
6 days ago
Blue 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 healthcare system in California.
Key Responsibilities:- Review and Render Decisions: Review pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, legal and regulatory requirements.
- Clinical Decision-Making: Provide medical decision-making and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges.
- Training and Development: Train BSC utilization and care management staff, including physicians, psychologists, nurses, social workers, and others as needed.
- Clinical Reviews: Perform clinical reviews to support utilization management and fraud, waste, and abuse case evaluations.
- Quality Improvement: Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members.
- Project Participation: Participate on projects and committees as necessary.
Requirements:
- Medical Degree: A Medical degree (M.D.) and 12 years' experience, including a minimum of 5 years' behavioral health clinical experience, preferably including hospital experience.
- California State Medical License: Unrestricted California State Medical License required.
- Board Certification: Board Certification in one of ABMS categories, preferably in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Association (AOA).
- Experience: A minimum of 5 years of experience in active clinical behavioral health practice with active recent inpatient psychiatric hospital experience (within the past five years) is desirable.
- Health Plan Experience: A minimum of 3-5 years of Health Plan experience in Medicare Advantage utilization management, case review, and/or quality improvement activities in a managed care setting is preferred but not required for this position.
- Communication Skills: 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.
- Collaboration Skills: 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 behavioral, project management, and more.
- Knowledge of MHPAEA: Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855, and all regulatory and compliance requirements.
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