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.
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