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Medical Director, Utilization Management - Concurrent Review at Blue Shield of California

Los Angeles, California, United States -

Full Time

Start Date

Immediate

Expiry Date

22 Jul, 26

Salary

379440.0

Posted On

23 Apr, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization management, Clinical review, Medical necessity criteria, Case management, Population health, Quality improvement, Medicare, Medi-Cal, NCQA accreditation, Data analysis, Leadership, Communication skills, Time management, Microsoft Office, Critical thinking, Strategic planning

Industry

Hospitals and Health Care

Description

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 Medical Director, Utilization Management - will report to the Sr. Medical Director, Utilization Management. 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 membership. These functions include performance of pre-service, concurrent and retrospective utilization review, and provider claims dispute reviews. In addition, the Medical Director, Utilization Management will assist in clinical oversight of coordination of care, case management, Health risk assessment and Individualized Care plans (ICPs). The Medical Director, Utilization Management - facilitates performance management and goals in alignment with organizational goals for the membership. Moreover, the Medical Director, Utilization Management - 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 members. 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

The Medical Director will lead clinical review activities, including pre-service, concurrent, and retrospective utilization management. They will also contribute to organizational health initiatives and provide clinical oversight for care coordination and individualized care plans.