Medical Director, Utilization Management - Promise Health Plan

Your Role

The Promise Health Plan Medical Director provides clinical leadership within the Blue Shield Promise Office of the CMO. The Medical Director’s duties include oversight and management of the clinical processes in support of member health initiatives, utilization management, care and case management, and clinically related functions. These functions include performance of pre-service, concurrent and retrospective utilization review, and retrospective provider claims dispute reviews. The Medical Director also provides physician oversight and support for various aspects including, but not limited to, Appeals and Grievances, provider dispute resolution, and peer review. Moreover, the Promise Chief Medical Officer will assign or delegate the Medical Director to lead or meaningfully contribute to Promise Health Plan priorities and transformative initiatives that continue to improve the health and wellbeing of 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, measurement of health care quality (HEDIS and CAHPS) and California Department of Health Care Services’ population health strategies to reduce health care inequities in vulnerable populations and communities of color. The Blue Shield Promise Medical Director works collaboratively with Blue Shield’s 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.

Finally, at the direction of the Promise Chief Medical Officer or VP, Medical Director, Medical Management, 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 clinical reviews (pre-service authorizations, concurrent review, provider claims disputes or others) within standards of care, regulatory, and compliance standards.
• Provide clinical review and resolution of appeals and grievances cases within compliance standards.
• Support process improvement and optimization efforts.
• Participate and lead discussions in cross-functional forums such as long-length of stay rounds, interdisciplinary care rounds, and assisting case management and other departments as needed.
• Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization and externally with provider groups and community partners.
• Support Chief Medical Officer, VP Medical Director, Medical Management, and Senior Medical Director in strategic initiatives by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver.
• Understand and abide by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program.
• Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
• Participate in medical director on-call schedule including weekends, holidays and evenings.
• Any other duties assigned by CMO and/or VP Medical Director, Medical Management and/or Senior Medical Director.

Your Knowledge and Experience

• Medical degree (M.D./D.O.)
• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice)
• Minimum 5 years direct patient care experience post residency
• Maintain Board Certification in one of ABMS or AOA recognized specialty required (preferably Internal Medicine or Family Practice)
• 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 and/or Requirements for Behavioral Health
• Experience with working in and/or with a Health Plan setting is preferred.
• Knowledge of Medi-Cal regulatory requirements, benefits and available resources is preferred.
• Knowledge of the wide ranges of psychosocial challenges, social determinants and health care inequities in diverse communities.
• Comfortable with written and verbal communication skills, analytical, time management and organizational skills. Proficient with computer programs such as Microsoft Excel, Outlook, Teams, Word, and PowerPoint.