Medical Director, Utilization Management - Promise Health Plan

Your Role

The Promise Health Plan Medical Director provides clinical leadership within the Blue Shield Promise Office of the CMO. 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 and Medicare regulatory requirements, NCQA guidelines, 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 of color. 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.

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)
• Minimum 5 years direct patient care experience post residency
• Maintain Board Certification in one of ABMS or AOA recognized specialty required (preferably Internal Medicine or Family Practice)
• 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 and/or Requirements for Behavioral Health
• 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.