Clinical Policy Innovator, Medical Leadership Position

5 days ago


Rancho Cordova, California, United States Blue Shield of California Full time
Senior Medical Director, Medical Policy Role Overview

Blue Shield of California seeks a skilled Senior Medical Director, Medical Policy to drive clinical policy innovations and provide medical leadership for our organization.

About the Job

This critical role will oversee the development and implementation of medical policies, ensuring we stay at the forefront of healthcare innovation. As a seasoned medical leader, you will work closely with cross-functional teams to provide clinical expertise and support for all medical, medication, and payment policy initiatives.

Key Responsibilities

  • Provide clinical oversight and input for Medical Policy operations, chairing the Medical Policy Committee.
  • Support the Blue Shield of California medication management process, working closely with the Pharmacy Services team to promote safe, effective, and cost-efficient pharmaceutical care for members.
  • Lead the BSC Payment Policy committee, overseeing and advising on payment policies, claims editing code loads, and other clinical code editing issues.
  • Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs (division of financial responsibilities).
  • Consult with Blue Shield of California legal to support fraud and abuse investigations, provider arbitrations, regulatory inquiries, and issues related to clinical policy, coding, or pricing.
  • Drive clinical thought leadership for the design and implementation of clinical policy innovation initiatives, such as Coverage with Evidence Development, and the development of robust approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devices.

Requirements

  • Minimum of 2 years of previous medical leadership experience.
  • Minimum 5 years direct patient care experience post-residency.
  • Medical degree (M.D./D.O.).
  • Completed residency preferably in adult-based primary care specialty (e.g., Internal Medicine, Family Practice).
  • Maintain active, unrestricted California State Medical License required; maintain active, unrestricted Medical License in all additional assigned states required.
  • Maintain Board Certification in one of ABMS or AOA recognized specialty required (preferably Internal Medicine or Family Practice).

Compensation

The estimated salary range for this position is $254,545 to $360,000 per year, based on the location in California. Please note that salaries are based on factors such as experience, location, and current employee salaries for similar roles within the company.



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