The BSC Medical Management department is focused on ensuring our members get the right level of care, at the right time, and at the right cost. We do this by developing and deploying medical management capabilities that are aligned with industry best practices. This minimizes the impact of cost of healthcare and improved operational efficiency. Consistent with Blue Shield's values, the Medical Management department will deliver best-in-class health care management through the following: Maintain... more details
Your Role
The BSC Medical Management department is focused on ensuring our members get the right level of care, at the right time, and at the right cost. We do this by developing and deploying medical management capabilities that are aligned with industry best practices. This minimizes the impact of cost of healthcare and improved operational efficiency. Consistent with Blue Shield's values, the Medical Management department will deliver best-in-class health care management through the following: Maintain a focus on the care and service our members receive while exercising fiscal responsibility. Forge partnerships to ensure a collaborative approach to our members' care, resulting in improved healthcare outcomes. Build a foundation and infrastructure that leverages technology and supports innovative solutions. Promote a work culture that encourages teamwork and rewards exceptional performance while striving for continuous improvement.
The Medical Director, Potential Quality Issues, functions as a key member of the BSC utilization management review team. The Medical Director, Potential Quality Issues, will report to the VP, Medical Management.
The Medical Director reviews and makes determinations regarding Potential Quality Issues and Quality of Care reviews for all BSCPHP and BSC lines of business and products. The role will provide clinical oversight and address quality of care trends and opportunities with quality committees as well as Provider Relations/Networks to improve the member experience. The Medical Director will represent the Medical Management team in various committees and meetings to support Quality of Care work, including Access and Availability.
Your Work
In this role, you will:
Be available to the Clinical Quality Review Department to review member quality of care grievances to determine if there was a quality-of-care issue.
Be available for peer-to-peer discussions with providers and Medical Directors from independent provider associations (IPA) and medical groups (MG) to reach consensus on issues relating to the care of BSC members.
Communicates any educational or corrective action plans to address identified quality concerns.
Able to combine a thorough knowledge of BSC medical and pharmacy policy, state and federal laws and regulations, and network design; with excellent clinical experience and rational decision making in order to make fair and consistent determinations for BSC members.
Work with other BSC staff and will provide clinical expertise to other key BSC divisions including Pharmacy Services, the Medical Policy Department, and the Law Department.
Adjudicate member reviews in an efficient and timely manner that complies with all regulatory requirements.
Strong decision-making, organizational, planning, and problem-solving skills, as well as strong interpersonal and communication skills are needed to effectively interact with staff, team members and others in a professional and tactful manner.
Job Abstracts is an independent Job Search Engine. Job Abstracts is not an agent or representative and is not endorsed, sponsored or affiliated with any employer. Job Abstracts uses proprietary technology to keep the availability and accuracy of its job listings and their details. All trademarks, service marks, logos, domain names, and job descriptions are the property of their respective holder. Job Abstracts does not have its members apply for a job on the jobabstracts.com website. Additionally, Job Abstracts may provide a list of third-party job listings that may not be affiliated with any employer. Please make sure you understand and agree to the website's Terms & Conditions and Privacy Policies you are applying on as they may differ from ours and are not in our control.
Welcome to Job Abstracts
We would like to take a second to Welcome You to Job Abstracts, the nation’s largest Pure Job Board. With over 3.1 million job listings from 15,000+ Companies & Organizations, we help job searchers find careers that match their interests. As an anonymous user, you have probably discovered how easy our system is to use. However, you have just scratched the surface of what we can offer.
We encourage you to Register so you can use our most powerful features: searching with multiple terms, setting up multiple locations, establishing favorite companies, and accessing your search history. If you find a job you like, you can apply directly for it, and then, keep notes on it. We will also keep a lookout for jobs that match your search terms and email you when we find something you may like.
You can register for free and the system is free to use. If you like our system so far, click on Register and unlock the power required by serious job searchers.
Any time you conduct a search, the system shows you job matches, ranked by their Relevance Score (RS).
The score is calculated by a proprietary algorithm that uses Intelligent Machine Learning.
The Relevance Score tells you how well the job opportunity matches your search term or terms.
When not logged in, the system is limited to one search term. Scores for single term matches are usually lower.
When you register, log in, and set up multiple terms prioritized by importance, the jobs found for you will receive a much higher Relevance Score.