Senior Medical Director, Medical Policy

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 Senior Medical Director, Medical Policy will report to the Vice President of Medical Management. In this role you will be accountable for working in partnership with other leaders to provide clinical support for all medical, medication, and payment policy initiatives. In addition, you will be the clinical driver for medical policy innovations, supporting medical payment operations, leading the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, and functioning as the in-house expert and trainer for staff related to medical, medication, and payment policy, pricing, and coding.

Your Work

In this role, you will:

• Provide clinical oversight, input, and support for Medical Policy operations. Chair the Medical Policy Committee.
• Provide medical support and input for the Blue Shield of California medication management process, including working closely with Pharmacy Services team to promote safe, effective, and cost-efficient pharmaceutical care for members. Chair the Pharmacy and Therapeutics Committee; provide medical expertise in daily clinical rounds for drug authorization case review.
• Provide medical support and input for the BSC Payment Policy committee, overseeing and advising about payment policies, claims editing code loads, and other clinical code editing issues; Chair the Payment Policy Committee
• Provide subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, and provider DOFRs (division of financial responsibilities).
• Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims.
• Consult with Blue Shield of California legal to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issues.
• 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.
• Act as Blue Shield’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 staff to resolve issues with Blue Shield providers related to clinical policy, coding, and billing.
• Facilitate IPA/MG and Provider education seminars regarding medical, medication and payment policy.

Blue Shield of California’s mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California’s top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we’re going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average
• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment – roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork – Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

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