Your Role
The Medical Director, Operations (Lead) provides clinical leadership within the BSC / BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, 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, Appeals and Grievances, and retrospective provider claims dispute reviews.
Additional functions will include leading Concurrent Review and SNF / LTC rounds as well as Interdisciplinary Care rounds.
The Lead Medical Director facilitates performance management of team and sets team goals in alignment with organizational goals.
The Medical Director, Operations (Lead) will report to the VP, Medical Management.
Moreover, the medical director leads or meaningfully contributes to the BSC / BSCPHP priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California Promise Health Plan members.
The Lead Medical Director serves as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization and externally with provider group and community partners.
They are 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.
Your Work
In this role, you will :
- Complete assigned clinical reviews (pre service requests, Appeals and Grievances, Provider Claims Disputes, 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
- Deliver clinical leadership by holding Concurrent Review and SNF / LTC rounds as assigned and facilitating Interdisciplinary Care Rounds as part of Care Management, supports Case Management
- Drives care coordination and case management functions for Palliative Care and Population Health Management by leading clinical initiatives as assigned and serving as a clinical, regulatory and quality improvement resource, clinical thought leader within the organization and externally with provider groups and community partners
- Serves as strategic support to the VP, Medical Director - Medical Management and Promise CMO with strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and / or serving as the initiative driver.
The lead may collaborate with teams in the implementation and operation of assigned initiatives
- Drive regulatory compliance through their knowledge of Medi-Cal and Medicare benefits and available resources
- Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
The lead will abide by all applicable laws and regulations as mandated by state and federal laws
- Participate actively assigned Committees
Medical Director, Operations (Lead)
The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions...
Medical Director, Operations (Lead)
The Medical Director, Operations (Lead) provides clinical leadership within the BSC/BSC Promise Health Plan (BSCPHP) Medical Management department for all clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions...
Physician Associate Director of Medical Operations
This position involves providing direct patient care and leading by example to ensure an exceptional patient experience. The role includes identifying and communicating opportunities for clinical quality improvement, driving patient ,and collaborating with leaders to support a caring treatment envir...
Director Clinic Operations
The Director, Clinic Operations is responsible for leading, planning, directing, monitoring and improving the overall performance for assigned care centers to achieve excellence in the delivery of daily operations. The Director, Clinic Operations has a key role in managing his or her area of respons...
Associate Director, Label Operations Team Lead
Design, synthesize, purify, and characterize drug candidates and/or chemical probes in target identification and validation, hit-to-lead, and lead optimization programs. Please understand that, as permitted by applicable law, if you have not been vaccinated against COVID-19 and an essential function...
Medical Director, Operations (Behavioral Health)
The Medical Director, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health. Review pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (F...
Director, Human Resources Operations - AHMC Seton Medical Center
Director, Human Resources Operations is responsible for leading the development, implementation and evaluation of all Human Resources plans and programs. Lead the human resources/organizational function and its systems and support services that ensure quality results in the identification, recruitme...
Medical Director, Operations (Medi-Cal)
The Medical Director will determine the medical necessity of requests or appeals for coverage of medications (oral and injectable), laboratory tests, office visits and consultations, procedures, surgeries, level of care, continuity of care, durable medical equipment (DME), and any other service that...
Associate Director, Field Medical Operations - ADFMO
We are looking for an Associate Director, Field Medical Operations to plays a critical role in driving the Field Medical Teams core functions and tactics. Partner with different functions within US Medical Affairs (field medical team, medical strategy, scientific communications, publications, congre...
Associate Director Medical Affairs Operations
Primary Responsibilities</u></strong></p><p>The below responsibilities will be executed in strategic alignment with the Director, Medical Affairs Operations and VP, Rare Disease, MA:</p><ul><li>Support operations and activities for rare disease MA leadership...