Job Description

Your Role

The Senior Medical Director, Medicare Programs is accountable for providing medical oversight, expertise and leadership to ensure the delivery of affordable, quality healthcare services across all Medicare Advantage product lines (Individual, Group, PPO). The role requires strong partnerships with the General Manager of the Medicare team, the Quality team, the Encounter team, Provider Partnerships and Network Management and as applicable other cross-functional leaders/team who impact Medicare performance. In addition, the work can only be successful in close collaboration with the delivery system partners who are delegated for certain clinical and administrative functions. As such, the Senior Medical Director will need to have strong skills in influencing, leading by example to establish, maintain and support provider partnerships, with insights and experiences in both health plan and delivery system infrastructure.

The Senior Medical Director will think strategically, have strong leadership and management skills, and be distinguished for the ability to achieve results and quality outcomes. The ideal candidate will have a successful track record of clinical oversight and outcome based performance, understand critical components of accurate and timely submission of risk scores through encounter data, Medicare revenue and costs related to utilization management, case management, pharmacy management, Medicare Stars experience, general health plan knowledge and firsthand experience implementing clinical programs into delivery systems, and facilitation of good working relationships and management of IPA\'s, medical groups and integrated health systems.

The Senior Medical Director will manage a small team of Medical Directors, program managers, and supporting staff. This position reports to the Vice President Provider Performance, Quality and Affordability.

Your Work

In this role, you will:

• Engage Key Delivery System Partners

• Proactively engages with key delivery system partners to influence care delivery and to remove barriers to efficient, high-quality care for BSC Medicare Advantage members. These relationships include:
• Hospital leadership such as a Vice President for Medical Affairs, Chief of Medical Staff, Hospitalist group leader, Emergency Department director, or service line chairs to address areas of opportunity to reduce admissions and/or improve timeliness and success of discharges
• IPA/Medical Group leadership including the Medical and UM Directors to address areas of outlier performance on key metrics such as hospital bed days and non-emergent ED utilization
• IPA/Medical Group leadership including the Medical and Quality Directors to address areas of outlier performance on key metrics including HEDIS and CAHPS measures
• These discussions shall be informed by data and lead to agreed-upon actions that will be tracked and completed
• Work with internal Blue Shield of California partners

• Partner and collaborate with Medicare General Manager and team to ensure efforts are aligned with strategy and expected outcomes for the Medicare line of business
• Partner with network contracting and participate in BSC meetings that design and implement Value Based Pay for Performance and other incentive plans to ensure consistency of messaging and optimization of behavior change in the delivery system
• As part of the Regional Market Teams for Blue Shield of CA, partner with BSC Health Solutions peers including teams in utilization management, Medical Director concurrent review, ACO support, BSC Pharmacy and clinical quality improvement, among others
• When needed, help resolve issues from BSC providers regarding case and disease management programs. Help resolve issues from other BSC teams with providers
• Implement Region-specific Strategy

• Lead the creation of a region-specific strategy and plan to achieve utilization and quality goals/targets
• Develop a synchronized plan with the Network Management plan for business relationships with providers
• Develop a synchronized plan with Quality to achieve Quality outcomes with providers
• Responsible for monitoring the region-specific plan to ensure that the plan is executed as intended and periodically adjusting the plan as necessary, in order to achieve affordability, clinical quality, and member experience targets
• Manage the Medicare Advantage Regional Medical Director Team

• Oversee, train, and hold accountable a team of Medicare Advantage Regional Medical Directors and program managers to assist in carrying out the vision described above

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 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 , Join us!

Blue Shield of California