SENIOR MEDICAL DIRECTOR, BEHAVIORAL HEALTH & MEDICAL DIRECTOR, OPERATIONS (BEHAVIORAL HEALTH)
Company: Blue Shield Of California
Location: Long Beach
Posted on: October 8, 2024
Job Description:
Your RoleThe 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
WorkIn 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
necessaryQualificationsYour 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.#LI-SS8About Blue ShieldBlue 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.
Keywords: Blue Shield Of California, Altadena , SENIOR MEDICAL DIRECTOR, BEHAVIORAL HEALTH & MEDICAL DIRECTOR, OPERATIONS (BEHAVIORAL HEALTH), Executive , Long Beach, California
Didn't find what you're looking for? Search again!
Loading more jobs...