Medical Director, Utilization Management - FEP

Your Role

The Medical Director is a key member of the Medical Management team within the Healthcare Quality and Affordability business unit. 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 Sr. Medical Director, Medical Management. 

Your Work

In this role, you will:

• Provide medical decision-making and support for the prior authorization registered nurse (RN) team, facilitating appropriate use of resources, including safe and timely decisions. These duties will require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers

• 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 core competency

• 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

• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence 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 as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers

• An ability to understand overall managed care organization, business strategies, and financial metrics; strong interpersonal and communication skills are needed to effectively interact with employees and clients professionally

• Ability to lead and provide training and guidance to others

• Ability to work evenings and weekends as part of rotating on-call schedule

Your Knowledge and Experience

• Medical degree (M.D./D.O.)

• A minimum of 3 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required.

• A minimum of 5 years direct patient care experience post residency.

• Active recent hospital experience (within the past five years) is desirable. Strong clinical skills with prior experience in a primary care setting.

• A medical degree (MD or DO) with 5 or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review. 

• Completed residency preferably in adult based primary care specialty (e.g., Internal medicine, Family practice).

• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required

• 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 

  • Federa