Sr. Medical Director, Medical Policy Position Available In Ontario, New York

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 Sr. Medical Director, Medical Policy will report tothe Chief Medical Officer. In this role you will be accountable forensuring that all medical, medication, and payment policyinitiatives are in aligned with the scientific evidence andprofessional guidelines. You will lead a team that delivers medicalpolicy that adapts to new clinical innovations and supports medicalpayment operations, and training for staff in the accurateapplication of medical, medication, and payment policy, pricing,and coding. In addition to chairing the BSC Pharmacy &Therapeutics, Medical and Payment Policy Committees, you willprovide clinical leadership for all evidence-based medicinefunctions and partner closely with leaders of other businessfunctions to develop strategies to ensure that Blue Shield membersare receiving appropriate quality care. Your Work In this role, youwill: Provide clinical thought leadership for the design andimplementation of clinical policy innovation initiatives such asCoverage with Evidence Development, and the development of robustand efficient approaches to developing policies for emergingclasses of technology like molecular diagnostics and mobile/digitalpersonal health devices Chair the Medical Policy and Pharmacy andTherapeutics Committees Provide clinical leadership and medicalconsultation for the Blue Shield of California (BSC) medicationmanagement process, including working closely with the PharmacyServices team to promote safe, effective, and cost-efficientProvide medical expertise in daily clinical rounds for drugauthorization case review Chair the Payment Policy Committee andprovide clinical leadership for the BSC Payment Policy committee,overseeing and advising about payment policies and tacticalapproaches to ensure accurate coding of services Consult with BSClegal team to support fraud and abuse investigations, providerarbitrations, regulatory inquiries and issues, and litigationrelated to clinical policy, coding, or pricing issues Act as BSC’srepresentative to the Blue Cross Blue Shield Association (BCBSA)Technology Assessment process and the Medical Policy PanelParticipate on the California Technology Assessment Forum and otherrelated activities Partner with Network Management and ProviderPartnership teams by providing subject matter expertise forcontract and benefits coding decisions, including mandatedbenefits, provider contract language, provider DOFRs (division offinancial responsibilities), and providing clinical perspective toresolve issues with BSC providers related to clinical policy,coding, and billing. Provide subject matter expertise for pricingof new, zero-dollar, and other exceptional claims Present at IPA/MGand Provider education seminars regarding medical, medication andpayment policy ?Your Knowledge and Experience Minimum of 2 years ofprevious medical leadership experience Minimum of 5 years of directpatient care experience post residency Minimum of 8 years ofexperience developing evidence-based guidelines, medical policiesor performing systematic reviews of the medical literature Medicaldegree (M.D./D.O.) required. Master’s degree in epidemiology,health services or related degree is preferred Completed residencypreferably in adult based primary care specialty (e.g. InternalMedicine, Family Practice) Maintain active, unrestricted CaliforniaState Medical License required; Maintain active, unrestrictedMedical License in all additional assigned states required MaintainBoard Certification in one of ABMS, ABOS, or AOA recognizedspecialty required (preferably Internal Medicine or FamilyPractice) Has mastery level knowledge and skills within a specifictechnical or professional discipline with broad understanding ofother areas within the job function Outstanding verbal and writtencommunication skills Ability to lead through influence in amatrixed organization Experience performing utilization managementreviews is preferred Experience in a health plan or managed careorganization is preferred LI-JS3