Job Description

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, Utilization Management 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 the membership. These functions include performance of pre-service, concurrent and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews. 

The Medical Director, Utilization Management facilitates performance management and goals in alignment with organizational goals for the membership. Moreover, the Medical Director, Operations 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 members. You will also provide direction and leadership in compliance with regulatory requirements and key operational metrics and work collaboratively with the Director, Utilization Management to achieve these goals. 

Your Work

In this role, you will:

• Complete assigned clinical reviews (preservice requests, Concurrent Review, 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 membership as well as other lines of business, including Medicare
• Partner closely with the Sr. Medical Director, Utilization Management to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the membership
• Support Sr. Medical Director, Concurrent Review in coordinating the care of membership, to provide access to high-quality health care to these members
• Support Sr. Medical Director, Concurrent Review 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 in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal laws
• Any other assigned duties

Your Knowledge and Experience

• Medical degree (M.D./D.O.)
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Maintain Board Certification in one of ABMS or AOA categories required (preferably Internal Medicine or Family Practice)
• Minimum 5 years direct patient care experience post residency
• Demonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health, Federal Employee Program (FEP), Education/Training (delivers CME, CEU), Quality Improvement
• Knowledge of Medicare, California statutes and regulations including DMHC. Understanding of NCQA accreditation standards preferred
• Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual)
• 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 written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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