Medical Director, Operations (Medi-Cal)
Blue Shield of CA | |
United States, California, El Dorado Hills | |
4205 Town Center Boulevard (Show on map) | |
Oct 06, 2024 | |
Your Role The BSC/BSC Promise Health Plan (BSCPHP) Medical Management department is focused on ensuring our members get the right level of care, at the right time, and at the right cost. We do this by developing and deploying medical management capabilities that are aligned with industry best practices. This minimizes the impact of cost of healthcare and improved operational efficiency. Consistent with Blue Shield's values, the Medical Management department will deliver best-in-class health care management through the following: Maintain a focus on the care and service our members receive while exercising fiscal responsibility. Forge partnerships to ensure a collaborative approach to our members' care, resulting in improved healthcare outcomes. Build a foundation and infrastructure that leverages technology and supports innovative solutions. Promote a work culture that encourages teamwork and rewards exceptional performance while striving for continuous improvement. The Medical Director, Operations functions as a key member of the BSC Promise utilization management review team. The Medical Director, Operations will report to the VP, Medical Management or their designee. The Medical Director reviews and makes determinations regarding all member and provider requests for service including prior authorization, concurrent reviews, retrospective reviews, appeals, grievance resolution, provider disputes. 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 is based on medical necessity or that can be considered investigational. The Medical Director will evaluate appeals for the Blue Shield Promise Health Plan Medi-Cal lines of businesses. The Medical Director will be available to support Case Management, Population Health Management, and interdisciplinary care team rounds. Your Work In this role, you will:
Your Knowledge and Experience
Pay Range: The pay range for this role is: $ 155331.00 to $ 325743.00 for California. Note: Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles. #LI-SS8 |