Medical Director Operations
2 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 we are on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California.
Key Responsibilities:- Review pre- and post-service behavioral health service requests and render decisions based on member benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, legal and regulatory requirements.
- 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.
- Train BSC utilization and care management staff, which may include physicians, psychologists, nurses, social workers, and others as needed.
- Perform clinical reviews to support utilization management and fraud, waste, and abuse case evaluations.
- 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.
- Participate on projects and committees, as necessary.
- A Medical degree (M.D.) and 12 years' experience, including a minimum of 5 years' behavioral health clinical experience, preferably including hospital experience.
- Unrestricted California State Medical License required.
- Board Certification in one of ABMS categories, preferably in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Association (AOA).
- 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.
- 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.
- 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 behavioral, project management, and more.
- An ability to understand overall managed care organization, business strategies, and financial metrics; well-versed with most areas of behavioral health services and conditions, show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues.
- Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency.
- Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855, and all regulatory and compliance requirements.
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