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Medical Director, Operations
2 months 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- Psychiatric Inpatient Concurrent Review: Conduct thorough reviews of pre- and post-service behavioral health service requests to ensure medical necessity and adherence to Blue Shield of California medical policy, FEP medical policy, and legal and regulatory requirements.
- Medical Decision-Making: Provide medical decision-making and support for behavioral health review for all services requiring authorization or review, ensuring appropriate use of resources and facilitating safe and timely discharges.
- Telephonic Physician-to-Physician Discussions: Engage in clinical conversations with Blue Shield providers to discuss current members in various levels of care or receiving specialized services.
- Training and Education: Train BSC utilization and care management staff on behavioral health clinical practices and policies.
- Clinical Reviews: Perform clinical reviews to support utilization management and fraud, waste, and abuse case evaluations.
- Quality Management: Participate 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 to support the Medical Management team.
- Medical Degree: A Medical degree (M.D./D.O.) 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).
- Behavioral Health 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.
- Leadership Skills: An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
- Communication Skills: Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others.
- Collaboration Skills: Strong collaboration skills to effectively work within a team that may consist of diverse individuals with various skills.
- Business Acumen: An ability to understand overall managed care organization, business strategies, and financial metrics.
- Behavioral Health Knowledge: Well-versed with most areas of behavioral health services and conditions, with ability for rapid, accurate decision-making.
