Medical Director Operations
4 days ago
The 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 management of physician processes in support of utilization management and transactional functions for CalPERS membership. Key responsibilities include performance of pre-service, concurrent, and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.
Your Work- 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 for the CalPERS membership and other lines of business, including Medicare.
- Partner closely with the Director CalPERS Utilization Management to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the CalPERS membership.
- Support Director CalPERS Utilization Management in coordinating the care of CalPERS membership, including partnering with Included Health, to provide access to high-quality healthcare to these members.
- Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization for the CalPERS membership.
- Support Vice President Medical Director in strategic initiatives, whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver.
- 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.
- Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
- Participate actively in assigned Committees.
- Abide by all applicable laws and regulations as mandated by state and federal laws.
- Other duties as assigned.
- 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 is required.
- Board Certification in one of ABMS categories, preferably Internal Medicine, is required.
- 5 years' experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other healthcare administrative operations at the IPA or health plan level is preferred.
- Knowledge of Medicare, California statutes and regulations including DMHC and understanding of NCQA accreditation standards is preferred.
- Knowledge and skilled application of National evidence-based medical necessity criteria references MCG or InterQual is preferred.
- Experience in data analysis and key performance indicators KPI's to drive performance improvement is preferred.
- An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
- Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications.
- Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more.
- Excellent analytical, time management, and organizational skills.
- Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint.
The pay range for this role is: $155,331.00 to $325,743.00 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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