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Medical Director, Operations

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: June 8, 2024

Job Description:

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. This includes care in a hospital and medical tests and treatments for a wide variety of clinical scenarios. 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. 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.
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 motivate, guide, influence, train, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications.
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.
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 -

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

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