Your Role
The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of psychiatric inpatient concurrent review, pre- and post-service utilization review, and collaboration with Nurse Care Managers.
Your Work
In this role, you will:
- 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 (Federal Employee Program) medical policy, as well as legal and regulatory requirements
- Medical decision-making and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges
- Engage in telephonic physician-to-physician discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers
- Train BSC utilizations and care management staff which may include physicians, psychologists, nurses, social workers, and others as needed
- Perform clinical reviews to support utilization management and fraud waste and abuse case evaluations
- Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members
- Participate on projects and committees, as necessary
Qualifications
Your Knowledge and Experience
- A Medical degree (M.D./D.O.) and 12 years’ experience, including a minimum of 5 years’ behavioral health clinical experience preferably including hospital experience
- Unrestricted California State Medical License required
- Board Certification in one of ABMS categories, preferably in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Association (AOA)
- A minimum of 5 years of experience in active clinical behavioral health practice with active recent inpatient psychiatric hospital experience (within the past five years) is desirable
- A minimum of 3-5 years of Health Plan experience in Medicare Advantage utilization management, case review, and/or quality improvement activities in a managed care setting is preferred but not required for this position
- An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
- 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
- Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to behavioral, project management and more
- An ability to 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
- Well-versed with most areas of behavioral health services and conditions, show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency
- Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements. The ideal candidate will be a highly talented psychiatrist with managed care experience supporting utilization management of all levels in behavioral health
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.
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About Blue Shield
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 genuinely 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 continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
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.
Our Workplace Model:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office
- 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.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. 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.
Equal Employment Opportunity:
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. 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.
