Sr. Medical Director, FEP Utilization Management Position Available In Lafayette, Louisiana

Job Description:

Your Role The Medical Management team ensures that Blue Shieldis on the cutting edge of medical, medication, and payment policyto accelerate the emergence of a value-based health care system inCalifornia. The Senior Medical Director FEP Prior Authorization andPost Review will report to the Vice President, Medical Managementor their designee. In this role you will deliver and collaborate onclinical review activities, which includes management of thephysician processes in support of utilization management andtransactional functions for Federal Employee Program (FEP)membership. These functions include performance of pre-service andretrospective utilization review, Appeals and Grievances, andprovider claims dispute reviews. The Senior Medical Director forFEP Prior Authorization and Post Review facilitates performancemanagement and goals in alignment with organizational goals for theFEP membership. Moreover, this role leads or meaningfullycontributes to the Blue Shield priorities and transformativeinitiatives that continue to improve the health and wellbeing ofBlue Shield of California FEP members. You will also providedirection and leadership in compliance to regulatory requirementsand key operational metrics and work collaboratively with the VP ofMedical Management and Medical Directors in Utilization Managementto achieve these goals. Your Work In this role, you will: Completeassigned clinical reviews (IP Admission and Concurrent, Lower Levelof Care, Preservice requests, Post-service medical claim review,Provider Claims Disputes, Medical pharmacy, or others) withincompliance standards while supporting clinical staff in maintaininghigh quality clinical reviews and work products and processimprovement and optimization efforts for FEP membership Providesclinical leadership and HR oversight for FEP Medical Director teamPartner closely with the VP Medical Management and MedicalDirectors in Utilization Management to develop improved utilizationof effective and appropriate services, and support operationalimplementation of transformation initiatives for the FEP membershipSupport VP, Medical Management and Medical Directors in UtilizationManagement in coordinating the care of FEP membership to provideaccess to high-quality health care to these members Serve as aclinical, regulatory and quality improvement resource and clinicalthought leader within the organization Support Vice President,Medical Management in strategic initiatives whether by proposingclinical initiatives, providing expert input, shaping the strategy,and/or serving as the initiative driver Collaborate with teams inthe implementation and operation of assigned initiativesUnderstands and abides by all departmental policies and proceduresas well as the organization’s Standards of Conduct and CorporateCompliance Program Attends mandatory Corporate Compliance Programeducation sessions, as required for this position, including theannual mandatory Standards of Conduct class Participates inassigned Committees Abides by all applicable laws and regulationsas mandated by state and federal law Any other assigned duties YourKnowledge and Experience A Medical degree (M.D./D.O.) Completedresidency preferably in adult based primary care specialty (e.g.internal medicine, family practice) Maintain active, unrestrictedCalifornia State Medical License required Maintain BoardCertification in one of ABMS categories required (preferablyInternal Medicine) Minimum of 2 years of previous medicalleadership experience Minimum 5 years direct patient careexperience post residency in: Internal Medicine (e.g. Neurology,Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics,OBGYN), Adult based care, Internal Medicine (e.g. Neurology,Rheumatology), Family Practice (with 5 years of inpatientexperience), Psychiatry, Geriatrics, OBGYN Demonstrated proficiencyin at least 3 of the following:

MEDICARE/MEDICARE

STARS,NCQA/URAC/Quality Programs, Policies/Procedure, Litigation,SIU/Waste/Fraud/Abuse, Appeals/Grievances, CaseManagement/Population Health Knowledge and skilled application ofnational evidence-based medical necessity criteria references (MCGor InterQual) An ability to work independently to achieveobjectives and resolve issues in ambiguous circumstances Clear,compelling communication skills with demonstrated ability tomotivate, guide, influence, and lead others, including the abilityto translate detailed analytic analysis and complex materials intocompelling communications Strong collaboration skills toeffectively work within a team that may consist of diverseindividuals who bring a variety of different skills ranging frommedical to project management and more Excellent written and verbalcommunication skills Excellent analytical, time management andorganizational skills Proficient with computer programs such asMicrosoft Excel, Outlook, Word, and PowerPoint