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Medical Director Operations, Medicare & Medi-Cal

Company: CTI Education Group
Location: Oakland
Posted on: April 5, 2021

Job Description:

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 reviews

  • 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
    • 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 initiative driver.
    • Collaborate with teams in the implementation and operation of assigned initiatives.
    • Knowledge of Medicare and Medi-Cal benefits and available resources.
    • 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 Education
      • Deep experience working with Medi-Cal and/or Medicare populations
      • 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 preferred
      • 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 effectively
      • 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 communities.
      • 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 skills.
      • 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 laws.

Keywords: CTI Education Group, Oakland , Medical Director Operations, Medicare & Medi-Cal, Healthcare , Oakland, California

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