Medical Director, Operations (Behavioral Health) Rancho Cordova, CA, United States and 7 Posted[...]

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, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of psychiatric inpatient concurrent review, pre- and post-service utilization review, and collaboration with Nurse Care Managers.

Your Work

In this role, you will:

• Review pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirements
• Medical decision-making and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges
• Engage in telephonic physician-to-physician discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers
• Train BSC utilizations and care management staff which may include physicians, psychologists, nurses, social workers, and others as needed
• Perform clinical reviews to support utilization management and fraud waste and abuse case evaluations
• Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members
• Participate on projects and committees, as necessary