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Medical Director, Medical Operations - Concurrent Review

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: June 22, 2022

Job Description:

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to DE&I combines a focus on our people processes and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us!The mission of HCS, to improve member health while managing cost, is at the core of everything we do each day. Blue Shield is consistent in its pursuit of innovative strategies that control costs on every level of care. HCS serves the entire population and offers comprehensive care management solutions to cover the spectrum of care - from healthy members to those living with chronic conditions.As a leading provider of health care and insurance, BSC prides itself on being an innovative pioneer in the health services industry. Recently, the company has positioned itself to be an important player in California's effort to provide universal healthcare. Critical to the realization of BSC's mission, Health Care Services provides leadership and direction for health management, clinical quality improvement strategies, pharmacy and medical management, and optimally functioning management systems. In the past, Medicare has been a small fraction of our member population; however, as California demographics change, BSC will help care for much of the Medicare population.Your Role The Medical Director 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.Your WorkIn this role, you will:

  • Medical decision-making and support for the concurrent review case management registered nurse (RN) team, facilitating appropriate use of hospital resources, including safe and timely discharges. These duties will require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers.
  • 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 core competency.
  • 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.
  • 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.
  • An ability to work in high-pressure situations while maintaining good leadership and reasoning ability.
  • Strong collaboration skills to effectively work as a team that consist of MDs, RNs, 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; strong interpersonal and communication skills are needed to effectively interact with employees and clients in a professional and tactful mannAn ability to lead and provide training and guidance to others.Qualifications - ExternalYour Knowledge and Experience
    • 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.
    • A minimum of 5 years experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required.
    • Active recent hospital experience (within the past five years) is desirableStrong 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 managed care setting with hospital experience, since a large part of this position involves inpatient con-current review.
    • Unrestrictive license to practice medicine in the State of California.
    • Board certified in a in a recognized medical or surgical specialty (preferably Internal Medicine).Our Values
      • Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
      • Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
      • Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Keywords: Blue Shield of California, Rancho Cordova , Medical Director, Medical Operations - Concurrent Review, Executive , Rancho Cordova, California

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