Job Description

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Sr. Medical Director, Medical Policy will report to the Chief Medical Officer. In this role, you will be accountable for ensuring that all medical, medication, and payment policy initiatives are aligned with scientific evidence and professional guidelines. You will lead a team that delivers medical policy that adapts to new clinical innovations, supports medical payment operations, and provides training for staff in the application of medical, medication, and payment policies, pricing, and coding. Additionally, you will chair the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, and provide clinical leadership for evidence-based medicine functions, partnering with other business leaders to ensure appropriate quality care for members.

Your Responsibilities include:

1. Providing clinical thought leadership for policy innovation initiatives, including Coverage with Evidence Development and policies for emerging technologies like molecular diagnostics and digital health devices.
2. Chairing the Medical Policy and Pharmacy & Therapeutics Committees.
3. Leading clinical and medical consultation for medication management, collaborating with Pharmacy Services to promote safe, effective, and cost-efficient medication use.
4. Participating in daily clinical rounds for drug authorization case review.
5. Chairing the Payment Policy Committee and providing leadership on payment policies and coding accuracy.
6. Supporting legal and regulatory inquiries related to clinical policy, coding, and pricing.
7. Representing BSC in the Blue Cross Blue Shield Association's Technology Assessment process and Medical Policy Panel.
8. Engaging in activities like the California Technology Assessment Forum.
9. Partnering with Network Management and Provider teams on contract and benefits coding decisions, including provider language and resolving clinical policy issues.
10. Offering expertise on pricing for special claims.
11. Presenting at seminars and educational sessions for providers regarding policies.

Your Knowledge and Experience:

• At least 2 years of medical leadership experience.
• Minimum 5 years of direct patient care post-residency.
• At least 8 years developing evidence-based guidelines, policies, or systematic reviews.
• Medical degree (M.D. / D.O.) required; a master's in epidemiology or health services is preferred.
• Residency completed in adult primary care (e.g., Internal Medicine, Family Practice).
• Active, unrestricted California Medical License; additional state licenses as required.
• Board certification in a recognized specialty (preferably Internal Medicine or Family Practice).
• Expertise in a specific technical or professional area with broad understanding of related fields.
• Excellent verbal and written communication skills.
• Ability to lead influence in a matrix organization.
• Experience with utilization management and managed care is preferred.

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