Job 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 Sr. Medical Director, Medical Policy will report to the Chief Medical Officer. In this role you will be accountable for ensuring that all medical, medication, and payment policy initiatives are in aligned with the scientific evidence and professional guidelines. You will lead a team that delivers medical policy that adapts to new clinical innovations and supports medical payment operations, and training for staff in the accurate application of medical, medication, and payment policy, pricing, and coding. In addition to chairing the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, you will provide clinical leadership for all evidence-based medicine functions and partner closely with leaders of other business functions to develop strategies to ensure that Blue Shield members are receiving appropriate quality care.

Your Work

In this role, you will:

• Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives such as Coverage with Evidence Development, and the development of robust and efficient approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devices
• Chair the Medical Policy and Pharmacy and Therapeutics Committees
• Provide clinical leadership and medical consultation for the Blue Shield of California (BSC) medication management process, including working closely with the Pharmacy Services team to promote safe, effective, and cost-efficient
• Provide medical expertise in daily clinical rounds for drug authorization case review
• Chair the Payment Policy Committee and provide clinical leadership for the BSC Payment Policy committee, overseeing and advising about payment policies and tactical approaches to ensure accurate coding of services
• Consult with BSC legal team to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issues
• Act as BSC’s representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy Panel
• Participate on the California Technology Assessment Forum and other related activities
• Partner with Network Management and Provider Partnership teams by providing subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, provider DOFRs (division of financial responsibilities), and providing clinical perspective to resolve issues with BSC providers related to clinical policy, coding, and billing. 
• Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims
• Present at IPA/MG and Provider education seminars regarding medical, medication and payment policy

​Your Knowledge and Experience

• Minimum of 2 years of previous medical leadership experience
• Minimum of 5 years of direct patient care experience post residency 
• Minimum of 8 years of experience developing evidence-based guidelines, medical policies or performing systematic reviews of the medical literature
• Medical degree (M.D./D.O.) required. Master’s degree in epidemiology, health services or related degree is preferred
• 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, ABOS, or AOA recognized specialty required (preferably Internal Medicine or Family Practice)
• Has mastery level knowledge and skills within a specific technical or professional discipline with broad understanding of other areas within the job function
• Outstanding verbal and written communication skills
• Ability to lead through influence in a matrixed organization
• Experience performing utilization management reviews is preferred
• Experience in a health plan or managed care organization is preferred

#LI-JS3

Job Tags

Similar Jobs