Senior Medical Director, Medical Management

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 â€" 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 â€" Join us!


Job Summary

The Health Solutions team is made up of approximately 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision - to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health care costs to ensure all Californians have access to the care they deserve.

How do we do it? Through partnership, innovation, and thought leadership.

We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You'll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.

The Senior Medical Director, Medical Management oversees a group of Medical Directors in the Medical Care Solutions team to ensure the basic components of Medical and Quality Management are established and operating within corporate and regulatory guidelines. Oversees activities of clinical operations and medical management including utilization management, care management, and appeals and grievances to ensure Blue Shield of California standards are met. This role will also provide medical support for all product lines and strategic medical support toward the organization's mission and goals. Finally, the Senior Medical Director will think strategically, have strong leadership and management skills, and be distinguished for the ability to get things done and achieve results. The ideal candidate will have a successful track record in clinical decision-making, managing and leading physicians, health care plan knowledge, firsthand experience implementing clinical programs into delivery systems, and facility working with IPA's, medical groups, and hospital organizations. This position will report to the Vice President of Medical Care Solutions.

  • Oversees Medical Directors, Physician Advisors and Medical Management Administrators to ensure the basic components of Medical Management are established and operating within corporate and regulatory guidelines. This includes high volume functions such as utilization management, care management, and appeals and grievance reviews.
  • Provide physician expertise on the development and update of medical policies that guide Blue Shield medical necessity decision making, contributing to quality of care and cost savings for Blue Shield member in all lines of business.
  • Accountable for recruitment of Medical Directors and Physician Advisors to support the key functions of the team. This includes being responsible for the External Physician Advisor Program including recruitment, contracting and reimbursement, orientation, inter-rater assessment, and compliance with all applicable regulations, policies, and procedures.
  • Ensures compliance with regulatory, accreditation, and Blue Shield medical policies and procedures requirements as they pertain to medical decision-making, including documentation, use of evidence-based criteria, turn-around time requirements and ensuring that denial language meets Department of Managed Care regulatory criteria.
  • Has hiring, firing, promotion and reward authority within functional area, in accordance with organization guidelines. This includes responsibility for performance evaluations annually and ongoing staff competency
  • Determines organizational structures and reporting relationships subject to top management approval.
  • Participates as needed in representing Blue Shield of California in statewide activities (CMA, CAHMO, UMGA, IPAC, PBGH, etc.).
  • Provide clinical subject-matter expertise for internal stakeholder functions, committees, and projects/initiatives. These may involve various inter-disciplinary committees and workgroups requiring clinical or operational expertise and subject-matter expertise.
  • Provides medical support for all product lines and strategic medical support toward the organization's mission and goals.
  • Fosters healthy relationships between physicians, nurses, and non-clinical staff to achieve a holistic approach to member care.
  • In partnership with the Senior Directors of Utilization Management and Care Management, create best in class, community integrated programs that differentiate Blue Shield in the market with innovative solutions that embrace engagement, technology and partnership with members, providers, and vendors.
  • In partnership with the Appeals and Grievance (AGD) Director, design and launch special projects to improve the efficiency and effectiveness of Medical Director/AGD team.
  • Works with Provider Relations to ensure consistent, effective provider medical management oversight, an integrated approach to clinical, administrative, and operational network management, and consistent evaluation and monitoring of contractual compliance.
  • Works with Information Systems and Quality Management groups to ensure flow of information and support for high quality decision making.
  • Recommends operational plans and strategies that directly impact the efficiency of the department, business unit and overall organization, exhibits a positive public image of the organization.
  • Directs the execution of strategies established by functional leadership including new clinical programs that are supported by teams in Medical Care Solutions.
  • Establishes operational plans for functional area with short- to mid-term impact on results (e.g., 1-2 years).
  • Work requires a high degree of responsibility for resources, and frequently influences business decisions made by functional leadership.
  • Has budgetary accountability for functional area.
  • Responsible for creating workforce and staffing plans for department/unit to ensure availability of human capital necessary to accomplish departmental business results.
  • Other duties as assigned.


Knowledge and Skills
  • Medical degree (M.D./D.O.) including a minimum of 5 years' experience in active clinical practice in an adult-based primary care specialty (internal Medicine or Family Practice) and a minimum of 5 years in managed care management is required.
  • Experience with CPT coding, medical claims review, hospital billing, and reimbursement is required.
  • Unrestricted California State Medical License required.
  • Board Certification in one of ABMS categories, preferably Internal Medicine, required.
  • Requires broad management and leadership knowledge to lead project teams and/or multiple job areas.
  • Graduate degree or equivalent in healthcare management, finance or leadership, e.g. MBA, MPH, MHS, MHA is preferred.
  • Current Board Certification in an ABMS recognized specialty is required.
  • Active hospital experience (within the past 5 years) is desired.
  • 6+ years of management experience preferred including managing physicians.
  • 2+ years' experience in utilization management, case review, and/or quality improvement activities in a managed care setting is preferred

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.

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.EEO Policy