Your Role
The Medical Management team ensures that Blue Shield is on the cutting edge of utilization management reimagined to accelerate the development and sustainability of a value-based health care system in California. The Medical Director, Medical Operations - CalPERS 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 CalPERS members. These functions include performance of pre-service and retrospective utilization review, and operationalization of joint initiatives supporting CalPERS strategic goals.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
A Medical degree (M.D./D.O.); Completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice); Minimum 5 years direct patient care experience post residency
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 recognized specialty required (preferably Internal Medicine or Family Practice)
Relevant experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level
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
Your Work
In this role, you will:
Complete assigned clinical reviews (preservice requests, 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 CalPERS membership
Partner with the CalPERS Line of Business Director to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the CalPERS membership
Collaborate with nurse reviewer teams in the implementation and operation of assigned initiatives
Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization for the CalPERS membership
Support Vice President, Medical Director in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
Participate actively in assigned Committees and any other assigned duties
Your Work
In this role, you will:
Complete assigned clinical reviews (preservice requests, 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 CalPERS membership
Partner with the CalPERS Line of Business Director to develop improved utilization of effective and appropriate services and support operational implementation of transformation initiatives for the CalPERS membership
Collaborate with nurse reviewer teams in the implementation and operation of assigned initiatives
Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization for the CalPERS membership
Support Vice President, Medical Director in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
Participate actively in assigned Committees and any other assigned duties