Medical Director, Medical Operations - CalPERS

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of utilization management reimagined to accelerate the development and sustainability of a value-based health care system in California. The Medical Director, Medical Operations - CalPERS will report to the Vice President, Medical 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 CalPERS members. These functions include performance of pre-service and retrospective utilization review, and operationalization of joint initiatives supporting CalPERS strategic goals.

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.

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); Minimum 5 years direct patient care experience post residency
• 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)
• Relevant experience in managed care that can contribute to utilization management, case management, and/or quality improvement activities or other health care administrative operations at the IPA or health plan level
• Knowledge of Medicare, California statutes and regulations including DMHC. Understanding of NCQA accreditation standards preferred
• 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