Medical Director, Operations
5 days ago
The Medical Director, Operations will play a key role in ensuring the delivery of high-quality healthcare services to Blue Shield of California members. This position will be responsible for reviewing and making determinations regarding member and provider requests for service, including prior authorization, concurrent reviews, retrospective reviews, appeals, grievance resolution, and provider disputes.
Key Responsibilities- Review and make determinations regarding member and provider requests for service, including prior authorization, concurrent reviews, retrospective reviews, appeals, grievance resolution, and provider disputes.
- Determine the medical necessity of requests or appeals for coverage of medications, laboratory tests, office visits, and consultations, procedures, surgeries, level of care, continuity of care, durable medical equipment, and any other service based on medical necessity or that can be considered investigational.
- Evaluate appeals for the Blue Shield Promise Health Plan Medi-Cal lines of businesses.
- Be available to support Case Management, Population Health Management, and interdisciplinary care team rounds.
- Work with other Blue Shield of California staff to provide clinical expertise to other key divisions, including Pharmacy Services, the Medical Policy Department, and the Law Department.
- Adjudicate member reviews in an efficient and timely manner that complies with all regulatory requirements.
- Communicate any educational or corrective action plans to address identified quality concerns.
- 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).
- 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.
- 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.
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