California Physicians' Service - Rancho Cordova, CA
posted 4 months ago
The Medical Director, Operations (Potential Quality Issues) at Blue Shield of California plays a crucial role in the Medical Management department, which is dedicated to ensuring that members receive the appropriate level of care at the right time and cost. This position is integral to developing and implementing medical management capabilities that align with industry best practices, thereby minimizing healthcare costs and enhancing operational efficiency. The Medical Management department is committed to delivering top-tier healthcare management, focusing on member care and service while maintaining fiscal responsibility. The Medical Director will work collaboratively with various stakeholders to improve healthcare outcomes and foster a culture of teamwork and continuous improvement. In this role, the Medical Director will be a key member of the utilization management review team, reporting directly to the VP of Medical Management. Responsibilities include reviewing and making determinations regarding Potential Quality Issues and Quality of Care reviews across all lines of business and products. The Medical Director will provide clinical oversight, address quality of care trends, and collaborate with quality committees and Provider Relations/Networks to enhance the member experience. This position requires active participation in various committees and meetings to support Quality of Care initiatives, including Access and Availability. The Medical Director will also be responsible for reviewing member quality of care grievances, engaging in peer-to-peer discussions with providers, and communicating educational or corrective action plans to address identified quality concerns. A thorough understanding of BSC medical and pharmacy policy, state and federal regulations, and network design is essential, along with strong clinical experience and decision-making skills to ensure fair and consistent determinations for BSC members. The role demands excellent organizational, planning, and problem-solving skills, as well as strong interpersonal and communication abilities to interact effectively with staff and team members.