Description Our Company As a not-for-profit company, our mission says it all: To ensure all Californians have access to high-quality health care at an affordable price. Driving this mission means being an advocate for care. We have supported universal coverage since 2002 and have taken a market-leading stand on affordability by pledging to limit our net income to 2 percent, meaning we will give back all income over 2 percent to our members and the communities we serve. And since 2005, we have donated more than $200 million dollars to the Blue Shield of California Foundation. Health Care Services (HCS) The mission of HCS, to improve member health while managing cost, is at the core of everything we do each day. Blue Shield is consistent in its pursuit of innovative strategies that control costs on every level of care. HCS serves the entire population and offers comprehensive care management solutions to cover the spectrum of care - from healthy members to those living with chronic conditions. Opportunity As a leading provider of health care and insurance, BSC prides itself on being an innovative pioneer in the health services industry. Recently, the company has positioned itself to be an important player in Californias effort to provide universal healthcare. Critical to the realization of BSCs mission, Health Care Services provides leadership and direction for health management, clinical quality improvement strategies, pharmacy and medical management, and optimally functioning management systems. In the past, Medicare has been a small fraction of our member population; however, as California demographics change, BSC will help care for much of the Medicare population. The Medical Director 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. Functional areas of responsibility within Medical Management and Operations include:
Medical decision-making and support for the concurrent review case management registered nurse (RN) team, facilitating appropriate use of hospital resources, including safe and timely discharges. These duties will require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers.
The Medical Director will review pre- and post-service requests and render decisions based on the members 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 core competency.
The Medical Director will participate on projects and committees as necessary.
Qualifications Candidate Profile and Requirements The Medical Director will be a highly-talented, front-line medical management professional with deep clinical experience supporting concurrent review and utilization management. The ideal candidate will have a successful track record in clinical decision-making, working with IPA's, medical groups, and hospital organizations. Specific competencies include:
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. Active recent hospital experience (within the past five years) is desirable.
A minimum of 3-5 years of Health Plan experience in Medicare Advantage utilization management, case review, and/or quality improvement activities in a managed care setting is preferred but not required for this position.
Strong clinical skills with prior experience in a primary care setting.
Attributes/Characteristics: The successful candidate will have industry experience, strong leadership skills and will be a strong communicator. A genuine and results-oriented doctor will excel in this role. Additionally, the Medical Director should possess:
Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions
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
An ability to work in high-pressure situations while maintaining good leadership and reasoning ability
Strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers
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; strong interpersonal and communication skills are needed to effectively interact with employees and clients in a professional and tactful manner
An ability to lead and provide training and guidance to others
Candidate Profile and Requirements :
A medical degree (MD or DO) with five or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review
Unrestrictive license to practice medicine in the State of California
Board certified in a in a recognized medical or surgical specialty (preferably Internal Medicine)
More than 3-5 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required
Our Culture Blue Shield is dedicated to a healthy and happy workforce. Our aim is to hire people who will thrive in our environment and care about what we care about. When everyone is 100% responsible for sustaining our culture, then we maintain a great work place. Because we are a health care company, it is essential that employees hold personal wellness a priority no matter where he/she is with their health status.Our internal wellness program, Wellvolution, is an award-winning wellness program proven to boost employee health, enhance productivity, and reduce medical claims costs.We work hard to make it easy to live well at Blue Shield.Our culture is a mission-driven culture. We count on every employees help to make our mission a reality.While pursuing our mission and strategy, we expect that all employees are stewards of our company values.These values create our culture: Creates a trusting environment Trusted and Trusting Displays a genuine interest in peoples well being Valuing People Holds self and others accountable for achieving outcomes Results Oriented Effectively drives & leads change Agile and Nimble Actively seeks input from others across the enterprise Interconnected Fosters an environment of learning from both success and failure Creative Solutioning Demonstrates a commitment to the customer in everything they do Customer Centric Compensation BSC offers a competitive compensation package comprised of base salary, annual bonus, full employee benefits, and 401K with company match. Physical RequirementsOffice Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork Activity level: Sedentary, frequency most of work day.
Associated topics: bilingual, family, family medicine physician, family practice physician, general practice, nocturnist, outpatient, physician, practice physician, practitioner
* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.