Medical Director Operations, Medicare & Medi-Cal
Company: CTI Education Group
Posted on: April 5, 2021
Job Description - Medical Director Operations, Medicare &
Medi-Cal (20002GS) Job Description Medical Director Operations,
Medicare & Medi-Cal - 20002GS At Blue Shield of California we are
parents, leader, students, visionaries, heroes, and providers.
Everyday we come together striving to fulfill our mission, to
ensure all Californians have access to high-quality health care at
a sustainably affordable price. For more than 80 years, Blue Shield
of California has been dedicated to transforming health care by
making it more accessible, cost-effective, and customer-centric. We
are a not-for-profit, independent member of the Blue Cross Blue
Shield Association with 6,800 employees, more than $20 billion in
annual revenue and 4.3 million members. The company has contributed
more than $500 million to Blue Shield of California Foundation
since 2002 to have a positive impact on California communities.
Blue Shield of California is headquartered in Oakland, California
with 18 additional locations including Sacramento, Los Angeles, and
San Diego. We're excited to share Blue Shield of California has
received awards and recognition for - LGBT diversity, quality
improvement, most influential women in corporate America, Bay
Area's top companies in volunteering & giving, and one of the
world's most ethical companies. Here at Blue Shield of California,
we're striving to make a positive change across our industry and
the communities we live in - Join us! Description Job Description
The Medical Director provides clinical leadership within the Office
of the CMO for Blue Shield Promise Health Plan, which includes
management of the physician processes in support of utilization
management and transactional functions. These functions include
performance of pre service, concurrent and retrospective
utilization review, and non-UM transactional work including but not
limited to Appeals and Grievances, and retrospective provider
claims dispute reviews. Moreover, the medical director leads or
meaningfully contributes to the Office of the CMO priorities and
transformative initiatives that continue to improve the health and
wellbeing of Blue Shield of California 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, and measurement of health
care quality (HEDIS and CAHPS). The Blue Shield Promise Medical
Director works collaboratively with 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. 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 Responsibilities Clinical
- Complete assigned clinical reviews (pre service requests,
Appeals and Grievances, Provider Claims Disputes, pharmacy, or
others) within compliance standards.
- Support clinical staff in maintaining high quality clinical
reviews and work products.
- Support in process improvement and optimization efforts.
- Any other assigned duties.
- Clinical leadership
- Leads Concurrent Review and SNF/LTC rounds as assigned.
- Facilitates 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 provider group and community partners. Strategic
- Support Chief Medical Officer and Senior Medical Director in
strategic initiatives whether by proposing clinical initiatives,
providing expert input, shaping the strategy, and/or serving as the
- Collaborate with teams in the implementation and operation of
- Knowledge of Medicare and Medi-Cal benefits and available
- 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 assigned Committees.
- Abides by all applicable laws and regulations as mandated by
state and federal laws. Qualifications Knowledge, Experience and
- Deep experience working with Medi-Cal and/or Medicare
- At least 3 years experience in medical leadership, utilization
management, case management, or other health care administrative
operations at the IPA or health plan level.
- Knowledge of/experience working in a Health Plan setting
- Knowledge of Medicare, Med-Cal, NCQA guidelines preferred
- Considerable knowledge of a wide range of behavior and
psychosocial problems and their diagnosis and treatment
- Ability to express ideas clearly and concisely and execute work
- Excellent communication skills both orally and in writing
- Medical Degree (MD) or Doctor of Osteopathic Medicine (DO) from
an accredited University
- Completed residency training.
- Knowledge of the wide ranges of psychosocial challenges, social
determinants and health care inequities in diverse
- Knowledge and skilled application of National evidence based
medical necessity criteria references (MCG or Interqual).
- Excellent written and verbal communication skills.
- Excellent analytical, time management and organizational
- Proficient with computer programs such as Microsoft Excel,
Outlook, Word, and PowerPoint. License/Certification/Special
Training Physician licensed by the State of California, active and
unrestricted Board certification in an American Board of Medical
Specialties recognized specialty or subspecialty
- Valid CA Driver's License and proof of auto insurance coverage
required. Working Conditions
- Normal office conditions with some work in the community in
public places once we return to workplace from the COVID 19
pandemic. Primary Location : United States of
America-California-Oakland Other Locations : United States of
America-California-San Diego, United States of
America-California-Rancho Cordova, United States of
America-California-Monterey Park, United States of
America-California-Costa Mesa, United States of
America-California-El Dorado Hills, United States of
America-California-Woodland Hills Organization : Health Solutions
Schedule : Full-time Job Posting : Mar 24, 2021, 5:02:13 AM
External hires must pass a background check/drug screen. Qualified
applicants with arrest records and/or conviction records will be
considered for employment in a manner consistent with Federal,
State and local laws, including but not limited to the San
Francisco Fair Chance Ordinance. All qualified applicants will
receive consideration for employment without regards to race,
color, religion, sex, national origin, sexual orientation, gender
identity, protected veteran status or disability status and any
other classification protected by Federal, State and local
Keywords: CTI Education Group, Oakland , Medical Director Operations, Medicare & Medi-Cal, Healthcare , Oakland, California
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