Medical Director Operations Lead
4 weeks ago
Job Summary
The Medical Director, Operations Lead provides clinical leadership within the Blue Shield of California Medical Management department for all clinical review activities. This includes management of physician processes in support of utilization management and transactional functions. The role involves performance of pre-service, concurrent, and retrospective utilization review, Appeals and Grievances, and retrospective provider claims dispute reviews.
The Medical Director, Operations Lead will lead or meaningfully contribute to Blue Shield of California priorities and transformative initiatives that continue to improve the health and wellbeing of members. This role serves as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization and externally with provider groups and community partners.
Key Responsibilities
- Complete assigned clinical reviews within compliance standards while supporting clinical staff in maintaining high-quality clinical reviews and work products and process improvement and optimization efforts
- Deliver clinical leadership by holding Concurrent Review and SNF/LTC rounds as assigned and facilitating Interdisciplinary Care Rounds as part of Care Management, supports Case Management
- Drive care coordination and case management functions for Palliative Care and Population Health Management by leading clinical initiatives as assigned and serving as a clinical, regulatory, and quality improvement resource, clinical thought leader within the organization and externally with provider groups and community partners
- Serves as strategic support to the VP, Medical Director - Medical Management and Promise CMO with strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
- Drive regulatory compliance through knowledge of Medi-Cal and Medicare benefits and available resources
- Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
- Participate actively assigned Committees
Requirements
- 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
- Board Certification in one of American Board of Medical Specialties categories, preferably Internal Medicine, required
- Knowledge of/experience working in a Health Plan setting preferred
- Knowledge of Medi-Cal, Medicare, California statutes and regulations including DMHC, DHCS preferred
- Understanding of NCQA accreditation standards preferred
- Experience managing or arranging care for patients with behavioral and medical comorbidities as well as an understanding of social drivers of health, including programs available through health plans, counties, and the state for support preferred
- Ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
- Understanding overall managed care organization, business strategies, and financial metrics
- Listening, interpreting, negotiating, and consensus building in bringing business conflicts to successful resolution
Pay Range
The pay range for this role is: $ to $ for California.
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.
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