Medical Director, Healthcare Optimization Specialist
7 days ago
At Blue Shield of California, we are committed to advancing the healthcare system in the state. As a Medical Director, Healthcare Optimization Specialist, you will play a crucial role in ensuring that our medical management team stays at the forefront of medical, medication, and payment policy.
The successful candidate will report to the Senior Medical Director, Utilization Management, and will be responsible for delivering and collaborating on clinical review activities. This includes managing physician processes in support of utilization management and transactional functions for membership. These functions include performing pre-service, concurrent, and retrospective utilization reviews, as well as provider claims dispute reviews.
In this role, you will also assist in clinical oversight of coordination of care, case management, health risk assessments, and individualized care plans. Additionally, you will facilitate performance management and goals alignment with organizational objectives for membership.
Your Work
- Complete assigned clinical reviews (preservice requests, provider claims disputes, pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high-quality clinical reviews and work products and process improvement and optimization efforts for the membership and other lines of business.
- Partner closely with the Senior Medical Director, Utilization Management, to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the membership.
- Support the Senior Medical Director, Concurrent Review, in coordinating the care of the membership to provide access to high-quality healthcare to these members.
- Collaborate with teams in the implementation and operation of assigned initiatives.
- Understand and abide by all departmental policies and procedures, as well as the organization's Standards of Conduct and Corporate Compliance Program.
Your Knowledge and Experience
- MEDICAL DEGREE REQUIRED: M.D./D.O.
- Completed Residency 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 Categories Required (preferably Internal Medicine).
- Minimum 5 Years Direct Patient Care Experience Post-Residency.
- Demonstrated Proficiency in At Least 3 of the Following: Medicare/Medicare STARS, DSNP, Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health, FEP, Education/Training (delivers CME, CEU), Quality Improvement.
Salary Range:
The estimated salary range for this position is $230,000 - $330,000 per year based on the location in California.
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