Medical Director, Operations

4 days ago

Oakland, California, United States Blue Shield of California Full time

Your Role

The BSC/BSC Promise Health Plan (BSCPHP) Medical Management department is focused on ensuring our members get the right level of care, at the right time, and at the right cost. We do this by developing and deploying medical management capabilities that are aligned with industry best practices. This minimizes the impact of cost of healthcare and improved operational efficiency. Consistent with Blue Shield's values, the Medical Management department will deliver best-in-class health care management through the following: Maintain a focus on the care and service our members receive while exercising fiscal responsibility. Forge partnerships to ensure a collaborative approach to our members' care, resulting in improved healthcare outcomes. Build a foundation and infrastructure that leverages technology and supports innovative solutions. Promote a work culture that encourages teamwork and rewards exceptional performance while striving for continuous improvement. 

The Medical Director, Operations functions as a key member of the BSC Promise utilization management review team. The Medical Director, Operations will report to the VP, Medical Management or their designee.

The Medical Director reviews and makes determinations regarding all member and provider requests for service including prior authorization, concurrent reviews, retrospective reviews, appeals, grievance resolution, provider disputes. The Medical Director will determine the medical necessity of requests or appeals for coverage of medications (oral and injectable), laboratory tests, office visits and consultations, procedures, surgeries, level of care, continuity of care, durable medical equipment (DME), and any other service that is based on medical necessity or that can be considered investigational. The Medical Director will evaluate appeals for the Blue Shield Promise Health Plan Medi-Cal lines of businesses. The Medical Director will be available to support Case Management, Population Health Management, and interdisciplinary care team rounds. 

Your Work

In this role, you will:

Ability to combine a thorough knowledge of BSCPHP medical and pharmacy policy, state and federal laws and regulations, and network design; with excellent clinical experience and rational decision making in order to make fair and consistent determinations for BSC members.  Be available to the Clinical Quality Review Department to review member quality of care grievances to determine if there were quality-of-care issue. Be available for peer-to-peer discussions with providers and Medical Directors from independent provider associations (IPA) and medical groups (MG) to reach consensus on issues relating to the care of BSC members. Work with other BSCPHP staff and will provide clinical expertise to other key BSCPHP divisions including Pharmacy Services, the BSCPHP Medical Policy Department, and the Law Department. Adjudicate member reviews in an efficient and timely manner that complies with all regulatory requirements while working effectively with nursing and coordinator staff. Communicates any educational or corrective action plans to address identified quality concerns. Strong decision-making, organizational, planning, and problem-solving skills, as well as strong interpersonal and communication skills are needed to effectively interact with staff, team members and others in a professional and tactful manner.
 

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