Medical Director, Operations

• Be the medical decision-maker and support for the prior authorization registered nurse (RN) team, facilitating appropriate use of resources, including safe and timely decisions. These duties will require telephonic physician-to-physician discussions regarding current 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 member's benefits, medical necessity, Blue Shield of California medical policy as well as legal and regulatory requirements. The Medical Director must be well-versed in 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 in projects and committees as necessary
• Conduct problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions
• Work independently to achieve objectives and resolve issues in ambiguous circumstances
• Possess 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
• Work in high-pressure situations while maintaining good leadership and reasoning ability
• Demonstrate strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers
• Possess essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution
• 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
• Lead and provide training and guidance to others

• A minimum of 5 year's experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required
• A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting
• 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)

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

• Hybrid - In a business unit approved office a few times per year to 3 days per week, on average

• Office - In a business unit approved office 4+ days a week, on average. If the role you're applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Blue Shield of California