Join Blue Shield of California as a Senior Medical Director to lead clinical review activities and improve the health and well-being of FEP members. Drive initiatives for effective service utilization while ensuring compliance with regulatory standards.
Key Responsibilities
Complete assigned clinical reviews within compliance standards
Provide clinical leadership and HR oversight for FEP Medical Director team
Collaborate with VP of Medical Management and Medical Directors on utilization initiatives
Support care coordination for FEP membership
Serve as a clinical, regulatory, and quality improvement resource
Support strategic initiatives proposed by the Vice President of Medical Management
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 one of ABMS categories
Minimum 2 years of previous medical leadership experience
Minimum 5 years direct patient care experience post-residency
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 of national evidence-based medical necessity criteria references (MCG or InterQual)
Preferred Qualifications
Experience in complex clinical leadership roles
Strong collaboration skills
Excellent analytical, time management, and organizational skills
Proficiency with Microsoft Excel, Outlook, Word, and PowerPoint