Medical Director, Utilization Management - Concurrent Review

Blue Shield of California • Los Angeles, CA

1d

About The Position

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, Utilization
Management - will report to the Sr. Medical Director, Utilization Management. In
this role you will deliver and collaborate on clinical review activities, which
includes management of the physician processes in support of utilization
management and transactional functions for membership. These functions include
performance of pre-service, concurrent and retrospective utilization review, and
provider claims dispute reviews. In addition, the Medical Director, Utilization
Management will assist in clinical oversight of coordination of care, case
management, Health risk assessment and Individualized Care plans (ICPs).

The Medical Director, Utilization Management - facilitates performance
management and goals in alignment with organizational goals for the membership.
Moreover, the Medical Director, Utilization Management - leads or meaningfully
contributes to the Blue Shield priorities and transformative initiatives that
continue to improve the health and wellbeing of Blue Shield of California
members.

Our leadership model is about developing great leaders at all levels and
creating opportunities for our people to grow – personally, professionally, and
financially. We are looking for leaders that are energized by creative and
critical thinking, building and sustaining high-performing teams, getting
results the right way, and fostering continuous learning.

Responsibilities

• Deliver and collaborate on clinical review activities
• Management of the physician processes in support of utilization management and transactional functions for membership
• Performance of pre-service, concurrent and retrospective utilization review, and provider claims dispute reviews
• Assist in clinical oversight of coordination of care, case management, Health risk assessment and Individualized Care plans (ICPs)
• Facilitates performance management and goals in alignment with organizational goals for the membership
• Leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California members

What This Job Offers

• Job Type: Full-time
• Career Level: Director
• Education Level: No Education Listed
• Number of Employees: 1-10 employees