Regional Medical Director job Costa Mesa California
Regional Medical Director job Costa Mesa California
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Regional Medical Director Job

Employer Name: SpiderID: 13705321
Location: Costa Mesa, California Date Posted: 3/22/2024
Wage: Negotiable Category: Insurance
Job Code: 170023A-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.


Blue Shield of California (BSC) has been a leading non-profit provider of quality health insurance plans for 70 years, with a mission to ensure all Californians have access to high-quality health care at a reasonable price. Founded with the name of California Physicians' Service (CPS) in 1939, it now has 3.2 million members, 4,700 employees, one of the largest provider networks and more than 20 office locations, providing a wide range of commercial and government products throughout the state. BSC is headquartered in San Francisco, has over 20 corporate locations throughout the state, and a vast network of care facilities around the nation. The company contributes $30 million annually to the Blue Shield of California Foundation to fund nonprofit organizations that improve access to quality health care in California.

The organization's health insurance products include Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), dental, Medicare supplemental plan, accidental death and dismemberment, executive medical reimbursement, life insurance, vision, and short-term health plans.

The Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision - to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.

How do we do it? Through partnership, innovation, and thought leadership.

We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You'll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield mission.

Position Summary

The Regional Medical Director (RMD) is accountable for the utilization and quality performance of assigned geographic regions for all product lines (Commercial HMO/PPO, and Medicare in both Accountable Care Organization (ACO) and non - ACO relationships). The work of the RMD will include both the strategic partnership and non-partnership work needed to ensure that Blue Shield meets its quality and affordability strategic initiatives.

The RMD will report to the Senior Medical Director, Regional Medical Director Network.

Candidate Profile and Requirements

The ideal Regional Medical Director candidate will be an experienced medical management professional who is an innovative thinker, is results oriented, can lead by influence, and has a strong desire to drive change within the healthcare delivery system.

Specific competencies include:

Develop and implement a region-specific strategy to achieve the objectives of the position. The RMD is expected to effectively leverage his/her analytic, communication, and organizational skills to drive cost and quality strategies within the network including:

• Development of regional and sub-regional strategies, and a plan to achieve designated utilization and quality goals/targets.
• Using data and evidence based strategies to enhance provider and facility performance in utilization and clinical quality. In particular, the short-term focus over the next few years is to substantially reduce potentially avoidable inpatient facility utilization by improving ambulatory care and optimizing the use of other sites of care.
• The RMD shares responsibility for driving regional cost of healthcare performance and monitoring the region-specific plan to ensure that the plan is executed as intended, making periodic adjustments to the plan as necessary, in order to achieve desired affordability, clinical quality and member experience targets.

Work with Internal BSC Partners
• Provide clinical input to assist in the evolution of medical management strategy and best practice development. This includes the integration of traditional UM strategies, ACO and other delivery system model interventions which might influence practice patterns using an integrated approach.
• Partner with BSC Quality to support Quality Improvement strategy to achieve BSC Quality goals. Achieve BSC Quality Performance Guarantees for designated lines of business.
• Partner with network management to develop new methods to incentivize providers using Value Based Pay for Performance and other incentive plans to ensure consistency of messaging and optimization of behavior change in the delivery system.
• Participate on the Regional Market Teams to partner with BSC teammates, including utilization management, concurrent review, case management, ACO team, BSC Pharmacy and clinical quality improvement, markets, among others, to achieve regional goals.
• When needed, help resolve issues from BSC providers regarding case and disease management, or non-compliance with administrative requirements.
• For ACO work, the RMD's are accountable for meeting key targets set by HCQA to achieve annual plan set for total cost of care as delivered by their Accountable Care Organization partners
• Contribute to making Blue Shield of California a Great Place to Work

Engage Key Delivery System Partners
The RMD proactively engages with key delivery system partners to influence care delivery and remove barriers to efficient, high quality care for BSC members. These collaborations 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 thematic areas of opportunities that could reduce admissions and/or improve timeliness and success of discharges. In addition, work with the ACO team to influence changes in hospital care delivery through the partnership model.
• IPA/Medical Group leadership including the Medical and UM Directors to address hospital bed day and ED utilization opportunities including working with the ACO team to influence changes in care delivery and though the ACO collaboration model.
• Individual high volume providers who manage BSC members by providing feedback on issues such as discretionary use of services, quality metrics and performance, and hospital utilization.
• Implementation of targeted care for highly complex patients in collaboration with targeted groups
• Work with the ACO team to implement integrated care management strategies around high risk clinics, home care programs, advanced facility initiatives and external care management programs
• Attend key ACO clinical leadership meetings with executive level partners
• Support of HCC clinical programs and other Medicare Advantage programs and policies to improve financial performance , clinical quality , and member experience with targeted groups
• Work with multidisciplinary teams within Blue Shield to support design and Implementation of key strategic clinical programs
• Work with internal financial partners to address contractual requirements in line with strategic plan for targeted Primary care physicians, Specialist and Medical groups
• Work with Blue Shield of California staff to resolve issues with members that require physician level expertise and skill to resolve.

Subject Matter Expert
The RMD serves as a resource and subject matter expert for numerous BSC functions such as:

• Implementing regional and sub-regional strategies
• Development of new models for care delivery
• Serving as the effecter for various BSC initiatives
• Medical policy development
• Cost of Healthcare projects
• Clinical Quality improvement initiatives
• Delegation oversight

The successful candidate will have industry experience, strong leadership skills, build trusting relationships and will be a strong communicator. A genuine and results-oriented innovator will excel in this role. Additionally, the Regional Medical Director should possess:

Key Leadership Competencies
• Business Acumen
• Drive for Results
• Leadership Influence
• Interpersonal Excellence
• Integrity/Ethics/Trust
• Change Management
• Balanced Perseverance and Resilience
• Collaboration
• Communication
• Customer Focus
• Financial/Quantitative Acumen



•Active, unencumbered CA license (MD or DO)
•5-10 years managed care experience

•Prior health plan experience - specifically as a Regional Medical Director
•IPA/Medical Group experience with >100,000 enrollees
•Prior clinical work and board certification in Internal Medicine, Family Medicine, Pediatrics, or Emergency Medicine.

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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