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Job Description
Join Blue Shield of California as a Senior Medical Director, where you'll lead clinical review activities to enhance the health care of Federal Employee Program members. Collaborate with a dedicated team to drive transformative initiatives and ensure compliance with regulatory standards while promoting high-quality care.
Key Responsibilities
Complete assigned clinical reviews within compliance standards
Provide clinical leadership and HR oversight for FEP Medical Director team
Partner with VP Medical Management to improve service utilization
Coordinate care for FEP membership to provide access to quality health care
Serve as a clinical and regulatory resource within the organization
Support strategic initiatives proposed by the Vice President, Medical Management
Collaborate on implementation and operation of initiatives
Abide by departmental policies and organizational Standards of Conduct
Required Qualifications
Medical degree (M.D./D.O.)
Completed residency in adult-based primary care specialty
Active, unrestricted California State Medical License
Board Certification in an ABMS category
Minimum 2 years of previous medical leadership experience
Minimum 5 years direct patient care experience post-residency
Proficiency in Medicare/Medicare Stars, NCQA/URAC/Quality Programs
Knowledge of national evidence-based medical necessity criteria
Preferred Qualifications
Experience in case management/population health
Skills in litigation, waste/fraud/abuse management