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Medical Director, Medical Policy and Innovation
2 months ago
Blue Shield of California is seeking a highly skilled Medical Director, Medical Policy and Innovation to lead our medical policy and payment initiatives. As a key member of our Medical Management team, you will be responsible for providing clinical oversight and input for medical policy operations, chairing the Medical Policy Committee, and driving medical policy innovations.
Key Responsibilities- Medical Policy Operations
- Provide clinical oversight and input for medical policy operations, ensuring alignment with company goals and objectives.
- Chair the Medical Policy Committee, ensuring effective decision-making and collaboration among stakeholders.
- Medical Policy Innovations
- Develop and implement medical policy innovations, leveraging clinical expertise and industry knowledge to drive business growth and improvement.
- Collaborate with cross-functional teams to design and implement clinical policy innovation initiatives, such as Coverage with Evidence Development.
- Payment Policy and Coding
- Provide medical support and input for payment policy and coding initiatives, ensuring accurate and efficient claims processing.
- Chair the Payment Policy Committee, ensuring effective decision-making and collaboration among stakeholders.
- Subject Matter Expertise
- Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs.
- 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.
- Clinical Thought Leadership
- Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives, ensuring alignment with company goals and objectives.
- Collaborate with cross-functional teams to develop robust and efficient approaches to developing policies for emerging classes of technology, such as molecular diagnostics and mobile/digital personal health devices.
- Representation and Partnerships
- Act as Blue Shield's representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy Panel.
- Participate on the California Technology Assessment Forum and other related activities.
- Education and Training
- Facilitate IPA/MG and Provider education seminars regarding medical, medication, and payment policy.
- 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.
- Active Board Certification in one of ABMS categories, preferably Internal Medicine, required.
- Prior health plan experience - specifically with medical and medication policy development, technology assessment, and clinical coding preferred.
- Clinical work in a primary care discipline (Internal Medicine, Family Practice, Pediatrics) or General Surgery desired.
- Understanding of the California marketplace, including California health care laws and regulations desired.
