Vice President of Clinical Operations & Medical Management job San Francisco Cal
Vice President of Clinical Operations & Medical Management job San Francisco Cal
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Vice President of Clinical Operations & Medical Management Job

Employer Name: SpiderID: 13139914
Location: San Francisco, California Date Posted: 12/23/2022
Wage: Negotiable Category: Insurance
Job Code: 170015V-2191

Job Description:
Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California is focused on transforming health care by making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 3.5 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.

We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.



The Vice President, Medical Care Solutions (MCS) is a member of the senior leadership team of the Blue Shield Healthcare Quality and Affordability team and contributes to the overall strategy and goals for BSC by providing consistent, innovative leadership and direction to the design, implementation, analysis, monitoring and reporting of effective and efficient health management services across all product lines including HMO, PPO, and Medicare. This position is the executive leader who leads the clinical professional teams and support teams who provide care management programs to all BSC members. Designing, implementing and administering best practices for care management programs, and instilling continuous process improvement across all teams and services within this business unit are all an ongoing priority for this position. Responsibility includes accountability for the staff and department budget, policy and procedure administration, and compliance as it applies to end to end accountability for the care management continuum: from Medical Policy management and implementation all the way through to clinical Appeals and Grievances including, but not limited to the functions below:

• Clinical Operations: Utilization Management, Case Management, Disease Management for all Commercial lines of business, Medicare, and FEP
• Medical Directors: MD team supports Clinical Operations and the Appeals & Grievance team in Customer Experience
• Provider Dispute Resolution: highly regulated dispute function
• Medical Policy: implementation and management
• Enhanced Clinical Program: part of Medical Policy. Team built to identify, create and implement programs that deliver high value to our members and high value to BSC. Examples include: genetics program, hip/knee program (only one of its kind in the NATION), home sleep study program.
• Payment Policy: implementation and management, includes clinical code editing solution (ClaimsXten)
• Clinical Program Management: oversight and management of strategic partner programs (e.g. Nurse 24/7, Disease Management, Life Referrals, Advanced Imaging, etc.)
• Training & Support: training, auditing, coaching of MCS staff, inclusive of engagement and relational coordination interventions and support across entire division.
• Provider Communication & Education
• Medical Operations Analytics: operational reporting and analytics
• Medical Solutions & Support: team of process engineers, developers, and analysts responsible for delivering process improvements/re-engineering and solutions for MCS operations. Management and configuration of the UM and CM systems. Provides consultation and facilitation of strategic planning sessions across the division, including Markets.

The VP, Medical Care Solutions will interact and develop strong management relationships with the Healthcare Quality & Affordability Senior Leadership team, as well as with leaders in other key Business and Functional units at Blue Shield of California. This position will manage a large team throughout the state of approximately 470 employees and report to the Chief Health Officer.

Key Deliverables:

• Build a high functioning team that meets all performance goals, including cost of health care, administrative expense, customer service, clinical quality improvement, regulatory requirement satisfaction, and employee engagement
• Migrate best practices across all product lines
• Assess current structure and staffing and restructure as appropriate
• Implement, maintain, and improve IT systems required to support MM best practices for supporting the delivery of evidence-based, coordinated, patient-preference sensitive health and sick care for all BSC members
• Develop and implement robust performance and operational metrics for all processes and products, to include outcome metrics for specific products.
• Instill a culture of Continuous Process Improvement, identify, design and implement Process Improvement opportunities, implement new systems required to support medical management operations, and optimize Problem Management across all personnel and processes
• Overall responsibility for budget planning, forecast and tracking
• Continuously track the managed care environment to identify and implement innovative approaches to improving the quality of medical management processes and clinical outcomes for BSC members.


Specific Competencies include:
• Very strong operational leadership experience and skills.
• Ability to think enterprise-wide and cross-functionally to enable optimization of end-to-end processes that are not fully owned by the MCS team.
• Ability to lead, motivate and develop clinicians including nurses and physicians.
• Ability to create an environment that fosters creative and agile solutioning, process improvement, and program and product innovation that continuously creates incremental value for BSC customers/members.
• Management experience that includes managing at least 100 full-time employees, including physicians, and the responsibility for associated budget. Proven experience managing operation centers specifically in the medical or health services environment
• Minimum 5 - 10 years' experience in medical management and/or healthcare administration.
• Minimum 5 + years' experience managing operations and customer service teams in a large, complex environment
• Ability to lead and manage significant change. Extensive experience with Change and Organization Management.
• Should possess performance driven management style.
• Ability to implement performance matrix and outcomes matrix.
• In depth knowledge of all aspects of managed care medical management including UM/CM, Disease Management, Grievance and Appeals, Medical Policy, clinical claims review (professional and facility), shared decision making, patient engagement, disparities reduction, and Behavioral Health.
• Experience with or knowledge of national vendors in Disease Management.
• Demonstrated success in the creation, development and implementation of Process Improvement and the ability to instill that focus in a team.
• Strong leadership skills are a prerequisite, including excellent interpersonal, communications, problem solving and negotiating skills.
• Ability to work cross-functionally and collaboratively across the BSC leadership team
• Ability to think strategically and act tactically
• Proven Project Management experience applying industry methodologies and practices.
• Computer literate and able to utilize medical information systems effectively
• Proven ability to mentor and coach leaders in their respective teams
Desirable Requirements:
• Managing large teams in multiple locations
• Blues experience
• Training in CPI: Lean or Black Belt Training (Six Sigma)

• Bachelor's degree required
• Medical degree, PharmD, RN or equivalent degree preferred
• If MD, current board certification in an ABMS or ABOS recognized specialty and active, unrestricted license to practice in California
• Graduate degree in healthcare management, finance or leadership, e.g. MBA, MPH, MHS, MHA, etc. preferred

Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required:
Overnight Travel:
Vacation Time:

Contact Information:
Contact Name: Blue Shield of California Company Type:
Company: Blue Shield of California

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