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

Your Knowledge and Experience

• A Medical degree (M.D./D.O.) and 12 years' experience, including a minimum of 5 years' behavioral health clinical experience preferably including hospital experience
• Unrestricted California State Medical License required
• Board Certification in one of ABMS categories, preferably in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Association (AOA)
• A minimum of 5 years of experience in active clinical behavioral health practice with active recent inpatient psychiatric hospital experience (within the past five years) is desirable
• A minimum of 3-5 years of Health Plan experience in Medicare Advantage utilization management, case review, and/or quality improvement activities in a managed care setting is preferred but not required for this position
• 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 behavioral, project management and more
• An ability to understand overall managed care organization, business strategies, and financial metrics; strong interpersonal and communication skills are needed to effectively interact with employees and clients in a professional and tactful manner
• Well-versed with most areas of behavioral health services and conditions, show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency
• Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements. The ideal candidate will be a highly talented psychiatrist with managed care experience supporting utilization management of all levels in behavioral health

Pay Range:

The pay range for this role is: $ 155331.00 to $ 325743.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

#LI-SS8