Medical Director, Utilization Management - Promise

Job Description

The Healthcare Services team is committed to a single vision of transforming health care delivery for Blue Shield members. Within this framework, the Office of the Promise Chief Medical Officer (CMO) and its Medical Directors report up to the Healthcare Services leadership headed by the Blue Shield of California Chief Medical Officer. The Promise Chief Medical Officer also reports to the CEO and President of Promise Health Plan. This healthcare professional team works collaboratively to improve the quality of patient care and ensure all Californians have equitable access for their health care needs.

The Promise Health Plan Medical Director will report to the Promise Health Plan Senior Medical Director, Utilization Management.

The Promise Health Plan Medical Director provides clinical leadership within the Blue Shield Promise Health Plan. The Medical Director's duties include oversight and management of the clinical processes in support of member health initiatives, utilization management, care and case management, and clinically related functions. These functions include performance of pre-service, concurrent and retrospective utilization review, and retrospective provider claims dispute reviews. The Medical Director also provides physician oversight and support for various aspects including, but not limited to, Appeals and Grievances, provider dispute resolution, and peer review. Moreover, the Promise Chief Medical Officer will assign or delegate the Medical Director to lead or meaningfully contribute to Promise Health Plan priorities and transformative initiatives that continue to improve the health and wellbeing of Promise Health Plan members.

The Medical Director serves as a role model for other clinical staff and is a knowledgeable resource in Medi-Cal regulatory requirements, measurement of health care quality (HEDIS and CAHPS) and California Department of Health Care Services' population health strategies to reduce health care inequities in vulnerable populations and communities. The Blue Shield Promise Medical Director works collaboratively with Blue Shield's Medical Care Services (MCS) and other appropriate departments across product lines to identify and address opportunities to improve service, reduce administrative cost and support department and organizational business goals.

Finally, at the direction of the Promise Chief Medical Officer or VP, Medical Director, Medical Management, the Medical Director will be responsible for engaging in organization-wide quality improvement efforts and promoting a culture of continuous improvement throughout the organization and contracted provider partners in each regional market.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

In this role, you will:

• Complete clinical reviews (pre-service authorizations, concurrent review, provider claims disputes or others) within standards of care, regulatory, and compliance standards.
• Provide clinical review and resolution of appeals and grievances cases within compliance standards.
• Support process improvement and optimization efforts.
• Participate and lead discussions in cross-functional forums such as long-length of stay rounds, interdisciplinary care rounds, and assisting case management and other departments as needed.
• Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization and externally with provider groups and community partners.
• Support Chief Medical Officer, VP Medical Director, Medical Management, and Senior Medical Director in strategic initiatives by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver.
• Understand and abide by all departmental policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program.
• Attend mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
• Participate in medical director on-call schedule including weekends, holidays and evenings.
• Any other duties assigned by CMO and/or VP Medical Director, Medical Management and/or Senior Medical Director.

Qualifications

Your Knowledge and Experience

• Medical degree (M.D./D.O.)
• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice)
• Maintain Board Certification in one of ABMS or AOA recognized specialty required (preferably Internal Medicine or Family Practice)
• Minimum 5 years direct patient care experience post residency
• Experience with working in and/or with a Health Plan setting is preferred.
• Knowledge of Medi-Cal regulatory requirements, benefits and available resources is preferred
• Knowledge of the wide ranges of psychosocial challenges, social determinants and health care inequities in diverse communities
• Comfortable with written and verbal communication skills, analytical, time management and organizational skills. Proficient with computer programs such as Microsoft Excel, Outlook, Teams, Word, and PowerPoint.
• Demonstrated proficiency in at least three of the following:
• MEDICARE/MEDICARE STARS
• Dual Special Needs Plan (D-SNP)
• MEDI-CAL
• NCQA/URAC/Quality Programs
• Policies/Procedure development
• Clinical Subject Matter Expert for Litigation
• SIU/Waste/Fraud/Abuse
• Appeals/Grievances
• Case Management/Population Health
• Federal Employee Program (FEP)
• Education/Training (DELIVERS CME, CEU)
• Quality Improvement

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. 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 achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. 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 listen and communicate effectively, showing empathy by understanding others' perspectives.
• 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

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: