Medical Director of Policy Innovation
5 days ago
The Medical Director of Medical Policy will play a critical role in shaping the medical management strategy at Blue Shield of California. As a key member of the Medical Management team, you will be responsible for providing clinical oversight and input for medical policy operations, including chairing the Medical Policy Committee.
In this role, you will work closely with other leaders to provide clinical support for all medical, medication, and payment policy initiatives. You will be the clinical driver for medical policy innovations, supporting medical payment operations, leading the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, and functioning as the in-house expert and trainer for staff related to medical, medication, and payment policy, pricing, and coding.
Your Work- Provide clinical oversight, input, and support for Medical Policy operations. Chair the Medical Policy Committee.
- Provide medical support and input for the Blue Shield of California medication management process, including working closely with Pharmacy Services team to promote safe, effective, and cost-efficient pharmaceutical care for members. Chair the Pharmacy and Therapeutics Committee; provide medical expertise in daily clinical rounds for drug authorization case review.
- Provide medical support and input for the BSC Payment Policy committee, overseeing and advising about payment policies, claims editing code loads, and other clinical code editing issues; Chair the Payment Policy Committee.
- Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs (division of financial responsibilities).
- Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims.
- Consult with Blue Shield of California legal to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issues.
- Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives such as Coverage with Evidence Development, and the development of robust and efficient approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devices.
- 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.
- Partner with Network Management and Provider Partnership staff to resolve issues with Blue Shield providers related to clinical policy, coding, and billing.
- 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) is required.
- Unrestricted California State Medical License required.
- Active Board Certification in one of ABMS categories, preferably Internal Medicine, required.
- Require 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.
Pay Range: The pay range for this role is: $155,331.00 to $325,743.00 for California.
Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
-
Medical Director, Medical Policy and Innovation
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryBlue 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...
-
Medical Director of Policy Innovation
18 hours ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a highly skilled Medical Director of Medical Policy to join our team at Blue Shield of California. As a key member of our Medical Management team, you will play a critical role in ensuring that our medical, medication, and payment policies are at the forefront of innovation and excellence.Key ResponsibilitiesProvide clinical...
-
Medical Director, Medical Policy and Innovation
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleBlue Shield of California is seeking a highly skilled Medical Director to lead our Medical Policy and Innovation team. As a key member of our Medical Management team, you will play a critical role in shaping our medical, medication, and payment policies to drive a value-based healthcare system in California.Key ResponsibilitiesClinical Policy...
-
Medical Director, Medical Policy
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director of Medical Policy will report to the Vice President of Medical Management at Blue Shield of California. In this role, you will be accountable for working in partnership with other leaders to provide clinical support for all medical, medication, and payment policy initiatives.Key ResponsibilitiesProvide clinical oversight,...
-
Medical Director Operations
4 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Medical Director Operations - CalPERS will play a pivotal role in ensuring Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. Reporting to the Vice President Medical Management, this position will deliver and collaborate on clinical review activities, including...
-
Medical Director, Operations
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director, Operations - CalPERS will play a pivotal role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management, and will be responsible for delivering and collaborating on...
-
Medical Director Operations
4 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly skilled Medical Director to join our team at Blue Shield of California. As a key member of our Medical Management department, you will play a critical role in ensuring our members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesDevelop and deploy medical management...
-
Medical Director Operations
6 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob Title: Medical Director, OperationsBlue 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...
-
Medical Director Operations
4 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Medical Director, Operations (Behavioral Health) will be a key member of the Medical Management team at Blue Shield of California. This team is responsible for ensuring that the organization is at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California.In this role,...
-
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryThe Medical Director, Operations - CalPERS will play a critical role in ensuring that Blue Shield of California's medical management team remains at the forefront of medical, medication, and payment policy innovation. This position will report to the Vice President, Medical Management.Key ResponsibilitiesClinical Review and Management: Deliver and...
-
Medical Director Operations
18 hours ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryThe Medical Director, Operations (Behavioral Health) will play a critical role in ensuring that Blue Shield of California is at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California.Key ResponsibilitiesReview pre- and post-service behavioral health service requests and...
-
Medical Director Operations
22 hours ago
Rancho Cordova, California, United States Blue Shield Of California Full timeJob SummaryWe are seeking a highly skilled Medical Director Operations to join our team at Blue Shield of California. As a key member of our Medical Management team, you will play a critical role in ensuring that our organization is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system...
-
Senior Medical Director, Behavioral Health
2 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly skilled and experienced Senior Medical Director, Behavioral Health to join our team at Blue Shield of California. As a key member of our Medical Management team, you will provide leadership and expertise in behavioral health clinical strategy and subject matter expertise.Key ResponsibilitiesProvide oversight of the...
-
Senior Medical Director, Behavioral Health
3 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Medical Management team at Blue Shield of California is dedicated to 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. As the Senior Medical Director, Behavioral Health, you will report to the Vice President, Medical...
-
Medical Director, Operations
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly skilled and experienced Medical Director, Operations - CalPERS to join our team at Blue Shield of California. As a key member of our Medical Management team, you will play a critical role in ensuring that we are on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based...
-
Medical Director, Operations
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe 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...
-
Medical Director, Operations
4 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe 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...
-
Medical Director Operations
6 days ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryWe are seeking a highly skilled Medical Director to lead our CalPERS operations team. As a key member of our Medical Management team, you will be responsible for delivering and collaborating on clinical review activities, including management of physician processes in support of utilization management and transactional functions for CalPERS...
-
Medical Director, Operations
3 weeks ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Medical Director, Operations (Behavioral Health) will play a critical role in ensuring that Blue Shield of California remains at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California.This position will report to the Senior Medical Director, Behavioral Health and...
-
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Senior Medical Director, Behavioral Health will provide leadership to the behavioral health medical director team and have core responsibilities in the areas of psychiatric inpatient concurrent review, pre and post service utilization review, and collaboration with RN Care Managers.Key ResponsibilitiesLeadership and OversightProvide...
