Medical Director, Operations
3 weeks ago
Your Role
The Medical Director, Operations - Federal Employee Program, is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of inpatient concurrent review, pre and post service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Medical Director of Medical Operations.
Our Blue Shield of California medical directors’ function in a critical role to make sure care is appropriate for our members and meets present medical standards. We review member’s care before, during, and after it occurs. This includes care in a hospital and medical tests and treatments for a wide variety of clinical scenarios. Care is reviewed for the full spectrum of age groups. We also must stay on the cutting edge of medicine to be able to evaluate all requests. We must base our decisions on sound medical research and well-established national guidelines. These duties will require telephonic physician-to-physician discussions regarding testing, treatment, and hospitalized patients. The Medical Director must feel comfortable in clinical conversations with Blue Shield providers and be a good communicator as well. One must have essential listening, interpreting, negotiating, and consensus-building skills to bring any care conflicts to successful resolution. One also must have strong collaboration skills to effectively work as a team that consist of physicians, nurses, patient care coordinators, and case/disease managers. Teamwork is very important and very satisfying in this role.
Your Work
In this role, you will:
- Support the nurse team, facilitate appropriate use of resources, and provide safe and timely decisions.
- The Medical Director will review pre- and post-service requests and render decisions based on the member’s benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, as well as legal and regulatory requirements. The Medical Director must be well-versed with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a plus.
- Strong interpersonal and communication skills are needed to effectively interact with other employees and clients in a professional and tactful manner.
- The Medical Director will participate on projects and committees as necessary.
- Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions.
- An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
- An ability to motivate, guide, influence, train, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications.
- An ability to work in high-pressure situations while maintaining good leadership and reasoning ability.
- Strong collaboration skills to effectively work in a team that consist of physicians, nurses, patient care coordinators, and case/disease managers.
- Essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution.
- An ability to understand overall managed care organization, business strategies, and financial metrics.
Your Knowledge and Experience
- A minimum of 5 years of experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required
- A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required
- Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting
- A medical degree (MD or DO) with five or more years of clinical experience, preferably in a hospital setting with hospital experience, since a large part of the FEP position involves inpatient concurrent review
- Unrestrictive license to practice medicine in the State of California
- Board certified in a in a recognized medical or surgical specialty in the area of one's training
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.
#LI-SS8
-
Medical Director, Operations
2 weeks ago
Rancho Cordova, California, 95741, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Medical Director provides clinical leadership within the Office of the CMO for Blue Shield Promise Health Plan, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of preservice, concurrent, retrospective utilization review, Appeals and...
-
Medical Director, Operations
1 week ago
Rancho Cordova, California, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Medical Director, Operations - Federal Employee Program, is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of inpatient concurrent review, pre and post service utilization review, and collaboration with RN...
-
Medical Director, Operations
1 week ago
Rancho Cordova, California, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Medical Director provides clinical leadership within the Office of the CMO for Blue Shield Promise Health Plan, which includes management of the physician processes in support of utilization management and transactional functions. These functions include performance of preservice, concurrent, retrospective utilization review, Appeals and...
-
Manager, Case Management Nurse Management
3 weeks ago
Rancho Cordova, California, 95741, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Care Management team is looking for a leader with Care Management experience who can help design and lead our Population Health management (PHM) Medi-Cal Care Management line of business. The Manager, Care Management will report to the Senior Manager of Care Management - PHM. In this role you will act as the practice and operational leader...
-
Case Management
3 weeks ago
Rancho Cordova, California, 95741, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Federal Employee Program (FEP) Care Management team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with their care including a multidisciplinary team and the member’s treating physicians. The Registered...
-
Product Manager, Principal
2 weeks ago
Rancho Cordova, California, 95741, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Medical Care Solutions team manages the clinical operations including utilization management, care management and clinical programs. The Product Manager will initially report to the Vice President of Medical Care Solutions. In this role you will be responsible for setting product vision and strategy via understanding of customer needs and...
-
Manager, Case Management Nurse Management
1 week ago
Rancho Cordova, California, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Care Management team is looking for a leader with Care Management experience who can help design and lead our Population Health management (PHM) Medi-Cal Care Management line of business. The Manager, Care Management will report to the Senior Manager of Care Management - PHM. In this role you will act as the practice and operational leader...
-
Case Management
1 month ago
Rancho Cordova, CA, 95741, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. The Behavioral Health Registered Nurse Case Manager...
-
Case Management
1 week ago
Rancho Cordova, California, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Federal Employee Program (FEP) Care Management team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with their care including a multidisciplinary team and the member’s treating physicians. The Registered...
-
Case Management
1 week ago
Rancho Cordova, California, Sacramento County, CA, United States Blue Shield of California Full timeYour Role The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians . The Behavioral Health Registered Nurse Case...
-
Medical Director, Operations
1 week ago
El Dorado Hills, California, El Dorado County, CA, United States Blue Shield of California Full timeYour Role The Medical Director, Commercial is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of pre and post service utilization review, and collaboration with RN Case and disease managers. This director position...
-
Assistant Nurse Manager-OR/Recovery
3 weeks ago
Rancho Cordova, California, 95670, Sacramento County, CA, United States Kaiser Full timeJob Summary: Manages activities of the unit(s), monitors quality, service and utilization standards. Supervises the day to day shift activities.Essential Responsibilities: Manages the units day to day clinical operations including practice standards, staffing, payroll, budgets, fiscal management, and quality improvement. Ensures the highest quality of care...
-
Assistant Nurse Manager-OR/Recovery
2 weeks ago
Rancho Cordova, California, 95670, Sacramento County, CA, United States Kaiser Full timeJob Summary: Manages activities of the unit(s), monitors quality, service and utilization standards. Supervises the day to day shift activities.Essential Responsibilities: Manages the units day to day clinical operations including practice standards, staffing, payroll, budgets, fiscal management, and quality improvement. Ensures the highest quality of care...
-
Service Unit Department Manager RN
3 weeks ago
Rancho Cordova, California, 95670, Sacramento County, CA, United States Kaiser Full timeJob Summary: Manages a large unit or multiple units providing ambulatory services. Ensures staff provides high quality, accessible, cost effective care, and patient focused services to members across the continuum, which comply with local, state, and federal requirements. Develops and maintains clinical practice standards, budgets, and staff...
-
Service Unit Department Manager RN
2 weeks ago
Rancho Cordova, California, 95670, Sacramento County, CA, United States Kaiser Full timeJob Summary: Manages a large unit or multiple units providing ambulatory services. Ensures staff provides high quality, accessible, cost effective care, and patient focused services to members across the continuum, which comply with local, state, and federal requirements. Develops and maintains clinical practice standards, budgets, and staff...
-
CDL Driver
2 weeks ago
McClellan Park, California, 95652, Sacramento County, CA, United States Beacon Roofing Full timeOverview: Joining Beacon Building Products as a CDL Driver – Crane Operator means becoming part of a values-driven organization. Our core principles guide everything we do: putting people first, prioritizing safety, doing what's right, taking pride in our work, continuously improving, and making significant strides towards a more sustainable future.Be...
-
Jr Photographer/Photo Assistant
4 weeks ago
Sacramento, California, California, 95813, Sacramento County, CA, United States Quad Full timeAs a global marketing experience company, Quad’s goal is to help our clients win every day. We use our data-driven integrated marketing and manufacturing platform to streamline solutions for our clients, reduce friction and enhance their marketing spend effectiveness. We’ve built a rich legacy by believing in our people, allowing them to act like owners...
-
Financial Analyst
2 weeks ago
Sacramento, California, 95811, Sacramento County, CA, United States Experis Full timeOur client is looking for hardworking, motivated talent to join their team. Don't wait… apply today! Job Title: Financial Analyst Location: Onsite in Sacramento, CA Salary: Starting salary is $110,000 What’s the Job? The Financial Analyst will support the company’s internal and external reporting of financial positions. Financial...
-
Sr. Director, Legal Counsel-Health Law
2 weeks ago
Oakland, California, Alameda County, CA, United States Blue Shield of California Full timeYour Role The Sr. Director, Legal Counsel will be a member of Blue Shield’s Law Department and will be a leader in the company. The Law Department partners with the company’s business leaders to embrace legal and ethical behavior in the achievement of the company’s mission. This team is highly regarded within the company and respected by management....
-
Unit Supply Specialist
3 weeks ago
Sacramento , California, Sacramento County, CA, United States United States Army Full timeELIGIBLE FOR UP TO A $20K SIGNING BONUS. Talk to you recruiter for details Job Overview: As the Unit Supply Specialist, you’ll be responsible for supervising and maintaining all Army supplies and equipment. You’ll receive, inspect, inventory, load and unload, store, issue, and deliver all supplies and equipment. You’ll also safely secure and control...
