JOB DESCRIPTION
Your Role

The Promise Health Plan Medical Director provides clinical leadership within the Blue Shield Promise Office of the CMO. The Medical Director’s 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 Shield’s 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 organization’s 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.

QUALIFICATIONS
Your Knowledge and Experience

• Minimum of two years of experience in direct patient care and 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 Knowledge and skilled application of State (DHCS, CCS) and national evidence based medical guidelines and medical criteria references
• Excellent written and verbal communication and interpersonal skills

Pay Range:

The pay range for this role is: $ 155,331.00 to $ 325,43.00 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.

ABOUT THE TEAM
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 diversity, equity, and inclusion 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!

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.

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain an accommodation within 30 days, your offer will be rescinded.