Medical Director, Operations (Potential Quality Issues)

California Physicians' Service - Rancho Cordova, CA

Full-time - Senior

Hybrid - Rancho Cordova, CA

Insurance Carriers and Related Activities

About the position

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.

Responsibilities

• Review and make determinations regarding Potential Quality Issues and Quality of Care reviews for all BSCPHP and BSC lines of business and products.
• Provide clinical oversight and address quality of care trends and opportunities with quality committees and Provider Relations/Networks.
• Engage in peer-to-peer discussions with providers and Medical Directors from independent provider associations and medical groups.
• Communicate educational or corrective action plans to address identified quality concerns.
• Adjudicate member reviews in an efficient and timely manner that complies with all regulatory requirements.
• Work with other BSC staff to provide clinical expertise to key divisions including Pharmacy Services, Medical Policy Department, and Law Department.

Requirements

• Doctor of Medicine (M.D./D.O.) degree required.
• 12 years of experience, including a minimum of 5 years in active clinical practice in an adult-based primary care specialty (internal medicine or family practice).
• Unrestricted California State Medical License required.
• Board Certification in one of ABMS categories, preferably Internal Medicine, required.
• Experience working for a Health Plan making medical or quality of care decisions or relevant experience in a Medical Group, IPA, or Health Plan.

Nice-to-haves

• Experience in Medicare or Medi-Cal benefits and policies.
• Ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
• Understanding of overall managed care organization, business strategies, and financial metrics.

Benefits

• Work from home flexibility
• Health insurance
• Dental insurance
• Vision insurance
• 401k plan
• Paid holidays
• Paid time off (PTO)
• Professional development opportunities