Behavioral Health Medical Director

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

Medical Care Solutions is dedicated to improving health outcomes for our members by being a community integrated health team to enable high quality, personalized, coordinated, and affordable care. Medical Care Solutions serves the Blue Shield population and offers comprehensive care management solutions to cover the spectrum of holistic 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. Critical to the realization of BSC's mission, Medical Care Solutions provides leadership and direction for health management, clinical quality improvement strategies, pharmacy and medical management, and optimally functioning management systems. Pursuant to our holistic strategy, Medical Care Solutions is expanding our Behavioral Health program that provides mental health services for our members.

The Behavioral Health Medical Director is a key member of the Clinical Operations and Medical Management team and will report to the Senior Medical Director on the Medical Care Solutions team. This utilization management position will have core responsibilities in the areas of psychiatric inpatient concurrent review, pre and post service utilization review, and collaboration with RN Care Managers.

  • The Behavioral Health Medical Director will review pre and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (spell out acronym) medical policy, as well as legal and regulatory requirements. Medical decision-making and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges.
  • These duties will require telephonic physician-to-physician discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers.
  • In partnership with our training team, take an active role in training BSC utilizations and care management staff which may include physicians, psychologists, nurses, social workers and others as needed.
  • Perform clinical reviews to support utilization management and fraud waste and abuse case evaluations.
  • Participate with the quality management function in the identification and analysis of medical information in order to develop interventions to improve quality of care and outcomes for our members.
  • The Behavioral Health Medical Director will participate on projects and committees, as necessary.
  • The Behavioral Health Medical Director must be well-versed with most areas of behavioral health services and conditions, show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency.
  • The Behavioral Health Medical Director candidate will be expected to have a deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements. The ideal candidate will be a highly talented psychiatrist with managed care experience supporting utilization management of all levels in behavioral health.


Knowledge and Experience
  • A minimum of 5 years of experience in active clinical behavioral health practice with active recent inpatient psychiatric 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 behavioral health.
  • A doctoral degree (MD, DO, with five or more years of behavioral health clinical experience preferably including hospital experience.
  • Unrestricted license or certification to practice medicine / behavioral health in the State of California Board certification in Psychiatry 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.
  • 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 within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to behavioral, project management and more.
  • 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 manner.
  • An ability to lead and provide training and guidance to others An ability to use the basic functions of Excel, Word, and Power Point.
  • The successful candidate will have background in behavioral health delivery, strong leadership skills and will be a strong communicator.
  • A genuine and results-oriented doctor will excel in this role.
  • Problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions.

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.
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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