Medical Directors Operations, Sr. Principal

Medical Directors Operations, Sr. Principal

Your Role

The Promise Health Plan Medical Director provides clinical leadership within the Blue Shield Promise Office of the CMO. The Medical Directors duties include oversight and management of the clinical processes in support of member health initiatives, utilization management, care and case management, and clinically related functions. These functions include performance of pre-service, concurrent and retrospective utilization review, and retrospective provider claims dispute reviews. The Medical Director also provides physician oversight and support for various aspects including, but not limited to, Appeals and Grievances, provider dispute resolution, and peer review.Moreover, the Promise Chief Medical Officer will assign or delegate the Medical Director to lead or meaningfully contribute to Promise Health Plan priorities and transformative initiatives that continue to improve the health and wellbeing of Promise Health Plan members.

The Medical Director serves as a role model for other clinical staff and is a knowledgeable resource in Medi-Cal and Medicare regulatory requirements,NCQA guidelines, measurement of health care quality (HEDIS and CAHPS) and California Department of Health Care Services population health strategies to reduce health care inequities in vulnerable populations and communities of color.The Blue Shield Promise Medical Director works collaboratively with Blue Shields Medical Care Services (MCS)and other appropriate departments across product lines to identify and address opportunities to improve service, reduce administrative cost and support department and organizational business goals.

Finally, at the direction of the Promise Chief Medical Officer or Promise Senior Medical Director, the Medical Director will be responsible for engaging in organization-wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization and contracted provider partners in each regional market.

Your Work

In this role, you will:

• Complete assigned clinical reviews (pre-service requests,Concurrent Review, Provider Claims Disputes, pharmacy, or others) within standards of care, regulatory, and compliance standards
• Provide clinical review and resolution for assigned appeals and grievance cases within compliance standards. These include:
  
  • Resolution of grievances with clinical issues
  • Resolution of appeals
  • Clinical appropriateness for grievance escalation and de-escalation cases
• Provide clinical review, resolution and severity leveling within compliance standards for potential quality of care cases
• Support clinical staff in maintaining high quality clinical reviews and work products
• Support process improvement and optimization efforts
• Lead Concurrent Review and SNF/LTC rounds as assigned
• Facilitate Interdisciplinary Care Rounds as part of the Model of Care for Care Management
• Lead clinical initiatives as assigned
• Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization and externally with BSC Regional Medical Directors, Provider groups and Community partners
• Support Chief Medical Officer, Senior Medical Director in strategic initiatives 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 organizations 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
• Participate in monthly on-call schedule
• Any other duties assigned by CMO and/or Senior Medical Director

Your Knowledge and Experience

• Minimum of seven years of relevant experience
• Minimum of three years of experience in direct patient care and two years medical leadership, that can contribute to utilization management, case management, or other health care administrative operations at the IPA or health plan level
• Medical Degree (MD) or Doctor of Osteopathic Medicine (DO) from an accredited University
• Completed residency training, preferably in a primary care specialty
• Physician licensed by the State of California, active and unrestricted
• Board certification in an American Board of Medical Specialties recognized specialty or subspecialty
• Knowledge of/experience working in and/or with a Health Plan setting preferred
• Knowledge of Medicare and Medi-Cal benefits and available resources
• Knowledge of Medi-Cal and Medicare regulatory requirements and NCQA guidelines
• Knowledge of a wide range of complex care and behavioral health needs , clinical management, and treatment
• Ability to express ideas clearly and concisely and execute work effectively
• Knowledge of the wide ranges of social drivers of health challenges and health care inequities in diverse communities

Salary 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.