Your Role 

The Medical Director, Commercial is a key member of the Medical Management and Operations staff within Health Care Services. This is a front-line utilization management position that has core responsibilities in the areas of pre and post service utilization review, and collaboration with RN Case and disease managers. This director position will report to the Medical Director of Medical Operations. 

Your Work 

 In this role, you will: 

• Be the medical decision-maker and support for the prior authorization registered nurse (RN) team, facilitating appropriate use of resources, including safe and timely decisions. These duties will require telephonic physician-to-physician discussions regarding current patients. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers 
• The Medical Director will review pre- and post-service requests and render decisions based on the member’s benefits, medical necessity, Blue Shield of California medical policy as well as legal and regulatory requirements. The Medical Director must be well-versed in most areas of medicine, show ability for rapid, accurate decision-making, and enjoy care review and the investigation and resolution of complex issues. Experience with CPT coding, medical claims review, hospital billing, and reimbursement is a core competency 
• The Medical Director will participate in projects and committees as necessary 
• Conduct problem analysis and clinical decision-making, which are the most critical skills, including the ability to independently formulate and implement solutions 
• Work independently to achieve objectives and resolve issues in ambiguous circumstances 
• Possess 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 
• Work in high-pressure situations while maintaining good leadership and reasoning ability 
• Demonstrate strong collaboration skills to effectively work as a team that consist of MDs, RNs, patient care coordinators, and case/disease managers 
• Possess essential listening, interpreting, negotiating, and consensus building skills to bring business conflicts to successful resolution 
• 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 
• Lead and provide training and guidance to others