Medical Director, Operations

Your Role

The Medical Director, Operations - Federal Employee Program, is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of inpatient concurrent review, pre and post service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Medical Director of Medical Operations.

Our Blue Shield of California medical directors' function in a critical role to make sure care is appropriate for our members and meets present medical standards. We review member's care before, during, and after it occurs. This includes care in a hospital and medical tests and treatments for a wide variety of clinical scenarios. Care is reviewed for the full spectrum of age groups. We also must stay on the cutting edge of medicine to be able to evaluate all requests. We must base our decisions on sound medical research and well-established national guidelines. These duties will require telephonic physician-to-physician discussions regarding testing, treatment, and hospitalized patients. The Medical Director must feel comfortable in clinical conversations with Blue Shield providers and be a good communicator as well. One must have essential listening, interpreting, negotiating, and consensus-building skills to bring any care conflicts to successful resolution. One also must have strong collaboration skills to effectively work as a team that consist of physicians, nurses, patient care coordinators, and case/disease managers. Teamwork is very important and very satisfying in this role.

Your Work

In this role, you will:

• Support the nurse team, facilitate appropriate use of resources, and provide safe and timely decisions.

• The Medical Director will review pre- and post-service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, as well as legal and regulatory requirements. The Medical Director must be well-versed with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a plus.

• Strong interpersonal and communication skills are needed to effectively interact with other employees and clients in a professional and tactful manner.

• The Medical Director will participate on projects and committees as necessary.

• Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions.

• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.

• An ability to motivate, guide, influence, train, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications.

• An ability to work in high-pressure situations while maintaining good leadership and reasoning ability.

• Strong collaboration skills to effectively work in a team that consist of physicians, nurses, patient care coordinators, and case/disease managers.

• Essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution.

• An ability to understand overall managed care organization, business strategies, and financial metrics.