Senior Medical Director Promise Health Plan at Blue Shield of CA in Palmdale, California

Job Description:

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to DE&I combines a focus on our people processes and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us!

Your Role

The Promise CMO team is responsible for oversight of the clinical quality, services and clinical outcomes experienced by Promise Health Plan members. The Sr Medical Director will report to the Promise Chief Medical Officer. In this role you will oversee Medical Directors-Operations, and Physician Advisors to ensure the basic components of Medical and Quality Management are established and operating within corporate and regulatory guidelines. Provides medical support for all product lines and strategic medical support toward the organization's mission and goals. Oversees activities of Medical Director-Operations organization including utilization management, case management and case review activities to ensure Blue Shield of California standards are met. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Recruits and oversees Physician Advisory network as needed.


• Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims.


• Works with Provider Relations to ensure consistent, effective provider medical management oversight, an integrated approach to clinical, administrative, and operational network management, and consistent evaluation and monitoring of contractual compliance.


• Recommends operational plans and strategies that directly impact the achievement of overall results for multiple departments and company-wide results, profitability, and/or public image of the organization.


• Directs the execution of strategies established by functional Leadership.


• Establishes operational plans for functional area with short- to mid-term impact on results (e.g., 1-2 years).


• Work requires a high degree of responsibility for resources, and frequently influences business decisions made by functional leadership.


• Has budgetary accountability for functional area.


• Responsible for making moderate to significant improvements of processes and policies to enhance performance of a function or corporate staff function.


• Recommends modifications to Blue Shield of California organizational polices.


• Determines organizational structures and reporting relationships subject to top management approval.


• Problems and issues faced are numerous and undefined requiring detailed information gathering, analysis and investigation to understand the problem. Problems are difficult and complex with impact to multiple departments, specialties or function and are typically solved through drawing from prior experience and analysis of issues.


• Manages a function or a corporate staff function that includes multiple teams led by managers and/or supervisors.


• Responsible for creating workforce and staffing plans for department/unit to ensure availability of human capital necessary to accomplish departmental business results.


• Has hiring, firing, promotion and reward authority within functional area, in accordance with organization guidelines.


• Other duties as assigned.
  
  

Your Knowledge and Experience

• Medical degree (M.D./D.O.) and 12 years' experience, including a minimum of 5 years experience in active clinical practice in an adult-based primary care specialty (internal Medicine or Family Practice) is required.


• Experience with CPT coding, medical claims review, hospital billing, and reimbursement is required.


• Unrestricted California State Medical License required.


• Board Certification in one of ABMS categories, preferably Internal Medicine, required.


• Requires broad management and leadership knowledge to lead project teams and/or multiple job areas.


• Active hospital experience (within the past 5 years) is desired.


• 6+ years of management experience preferred


• 2+ years experience in utilization management, case review, and/or quality improvement activities in a managed care setting is preferred

Our Values

• 
  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.

Additional Information

• About Company:
  o About Blue Shield of California: For more than 80 years, Blue Shield 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 7,500 employees, more than $21 billion in annual revenue and 4.5 million members. The company has contributed more than $500 million to the Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield is headquartered in Oakland, California with 21 additional locations including Sacramento, Los Angeles, and San Diego.
  o Our Benefits: At Blue Shield you can expect a comprehensive benefits program that offers choice and flexibility for our diverse workforce. These programs and resources include: Medical, Dental, and Vision plan benefits, 401(k) with employer match, paid time off (PTO), earned sabbatical time, paid nonprofit volunteer time, flexible work program, free online education, tuition reimbursement, a wellness reimbursement program, 12 weeks paid parental leave, and more.










• Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
  Please click here for further physical requirement detail.
















• EEO Footer:
  o EEO Footer: 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. 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.
  o Accommodations: Blue Shield is committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, services, programs and activities. To request a reasonable accommodation prior to your interview, please contact RehabWest, Inc at (760)759-7500.











• Requisition ID: 21002LF













• Posting Date: Oct 22, 2021











• Schedule: Full-time

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