Medical Director, Utilization Management - Commercial Prior Authorization Review

Your Role

The Medical Management team ensures that Blue Shield of California (BSC) 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, Utilization Management - Commercial Prior Authorization Review will report to the Senior Medical Director, Utilization 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 BSC Commercial and Medicare members. These functions include performance of pre-service and retrospective utilization review, and operationalization of joint initiatives supporting BSC 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

• Requires a Medical degree (M.D./D.O.)
• Requires completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice)
• Requires maintaining an active, unrestricted California State Medical License; Requires maintaining an active, unrestricted Medical License in all additional assigned states required
• Requires maintaining Board Certification in one of ABMS or AOA recognized specialty (preferably Internal Medicine or Family Practice)
• Requires 5 years direct patient care experience post residency
• Requires 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
• Demonstrated proficiency in at least three of the following: MEDICARE/MEDICARE STARS, Dual Special Needs Plan (D-SNP), MEDI-CAL, NCQA/URAC/Quality Programs, Policies/Procedure 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 is preferred
• Knowledge and skilled application of National evidence-based medical necessity criteria references (MCG or InterQual)
• 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
• Proficiency with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

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
• Collaborate with nurse reviewer teams in the implementation and operation of assigned initiatives
• Serve as a clinical, regulatory and quality improvement resources and clinical thought leader within the organization
• 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
• 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 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
• Collaborate with nurse reviewer teams in the implementation and operation of assigned initiatives
• Serve as a clinical, regulatory and quality improvement resources and clinical thought leader within the organization
• 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
• 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 and any other assigned duties