Blue California
January 4, 2021
Rancho Cordova, CA
Job Type
Work Setting


The mission of HCS, to improve member health while managing cost, is at the core of everything we do each day.  Blue Shield is consistent in its pursuit of innovative strategies that control costs on every level of care.  HCS serves the entire population and offers comprehensive care management solutions to cover the spectrum of care - from healthy members to those living with chronic conditions.
As a leading provider of health care and insurance, BSC prides itself on being an innovative pioneer in the health services industry. Recently, the company has positioned itself to be an important player in California’s effort to provide universal healthcare. Critical to the realization of BSC’s mission, Health Care Services provides leadership and direction for health management, clinical quality improvement strategies, pharmacy and medical management, and optimally functioning management systems. In the past, Medicare has been a small fraction of our member population; however, as California demographics change, BSC will help care for much of the Medicare population.
The Medical Director is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of inpatient concurrent review, pre and post service utilization review, and collaboration with RN Case and disease managers.  This director position will report to the Medical Director of Medical Operations.
  • Medical decision-making and support for the concurrent review case management registered nurse (RN) team, facilitating appropriate use of hospital resources, including safe and timely discharges. These duties will require telephonic physician-to-physician discussions regarding current hospitalized patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers.
  • The Medical Director will review pre- and post-service requests and render decisions based on the member’s benefits, medical necessity, Blue Shield of California medical policy, FEP medical policy, as well as legal and regulatory requirements. The Medical Director must be well-versed with most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency.
  • The Medical Director will participate on projects and committees as necessary.


Knowledge, Experience and Education

The Medical Director will be a highly-talented, front-line medical management professional with deep clinical experience supporting concurrent review and utilization management. The ideal candidate will have a successful track record in clinical decision-making, working with IPA's, medical groups, and hospital organizations.
Specific competencies include
  • A minimum of 5 years of experience in active clinical practice in an adult-based primary care specialty (preferably Internal Medicine or Family Practice) is required. Active recent 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.
  • Strong clinical skills with prior experience in a primary care setting.
The successful candidate will have industry experience, strong leadership skills and will be a strong communicator. A genuine and results-oriented doctor will excel in this role. Additionally, the Medical Director should possess:
  • Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions.
  • 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.
  • An ability to work in high-pressure situations while maintaining good leadership and reasoning ability.
  • Strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers.
  • Essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution.
  • 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 mannAn ability to lead and provide training and guidance to others.
Candidate Profile and Requirements
  • A medical degree (MD or DO) with five or more years of clinical experience, preferably in a managed care setting with hospital experience, since a large part of this position involves inpatient con-current review.
  • Unrestrictive license to practice medicine in the State of California.
  • Board certified in a in a recognized medical or surgical specialty (preferably Internal Medicine).
  • More than 3-5 years of experience working for a Medical Group, IPA, or Health Plan making decisions for Medicare Advantage utilization is preferred but not required.
Additional Information
  • About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We’re excited to share Blue Shield of California has received awards and recognition for – LGBT diversity, quality improvement, most influential women in corporate America, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we’re striving to make a positive change across our industry and the communities we live in – Join us!
  • Physical Requirements:
    Office Environment - roles involving part to full time schedule in Office Environment. 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.
  • EEO Footer: 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.
  • Requisition ID: 20002NY
  • Posting Date: Dec 21, 2020
  • Schedule: Full-time
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