Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization's Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• 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
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint