Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations - CalPERS will report to the Vice President, Medical Management. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for CalPERS membership. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Medical Director, Operations - CalPERS facilitates performance management and goals in alignment with organizational goals for the CalPERS membership. Moreover, the Medical Director, Operations - CalPERS leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California CalPERS members. You will also provide direction and leadership in compliance with regulatory requirements and key operational metrics and work collaboratively with the Director, CalPERS Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (preservice requests, Appeals and Grievances, Provider Claims Disputes, pharmacy, or others) 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 as well as 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 health care 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
• Understands and abides by all departmental policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates actively assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal laws
• Other duties as assigned

Your Knowledge and Experience

• 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 ABMS categories, preferably Internal Medicine, required
• 5 years' experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level preferred
• Knowledge of Medicare, California statutes and regulations including DMHC and understanding of NCQA accreditation standards preferred
• Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual) preferred
• Experience in data analysis and key performance indicators (KPI's) to drive performance improvement 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

Pay Range:

The pay range for this role is: $ 155331.00 to $ 325743.00 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.

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