Sr. Medical Director, Medical Policy

Job Description

Your Role

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 in aligned with the scientific evidence and professional guidelines. You will lead a team that delivers medical policy that adapts to new clinical innovations and supports medical payment operations, and training for staff in the accurate application of medical, medication, and payment policy, pricing, and coding. In addition to chairing the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, you will provide clinical leadership for all evidence-based medicine functions and partner closely with leaders of other business functions to develop strategies to ensure that Blue Shield members are receiving appropriate quality care.

Responsibilities

Your Work

In this role, you will:

• Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives such as Coverage with Evidence Development, and the development of robust and efficient approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devices
• Chair the Medical Policy and Pharmacy and Therapeutics Committees
• Provide clinical leadership and medical consultation for the Blue Shield of California (BSC) medication management process, including working closely with the Pharmacy Services team to promote safe, effective, and cost-efficient
• Provide medical expertise in daily clinical rounds for drug authorization case review
• Chair the Payment Policy Committee and provide clinical leadership for the BSC Payment Policy committee, overseeing and advising about payment policies and tactical approaches to ensure accurate coding of services
• Consult with BSC legal team to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issues
• Act as BSC’s representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy Panel
• Participate on the California Technology Assessment Forum and other related activities
• Partner with Network Management and Provider Partnership teams by providing subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, provider DOFRs (division of financial responsibilities), and providing clinical perspective to resolve issues with BSC providers related to clinical policy, coding, and billing.
• Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claims
• Present at IPA/MG and Provider education seminars regarding medical, medication and payment policy
  
  

Qualifications

Your Knowledge and Experience

• Minimum of 2 years of previous medical leadership experience
• Minimum of 5 years of direct patient care experience post residency
• Minimum of 8 years of experience developing evidence-based guidelines, medical policies or performing systematic reviews of the medical literature
• Medical degree (M.D./D.O.) required. Master’s degree in epidemiology, health services or related degree is preferred
• Completed residency preferably in adult based primary care specialty (e.g. Internal Medicine, Family Practice)
• Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Maintain Board Certification in one of ABMS, ABOS, or AOA recognized specialty required (preferably Internal Medicine or Family Practice)
• Has mastery level knowledge and skills within a specific technical or professional discipline with broad understanding of other areas within the job function
• Outstanding verbal and written communication skills
• Ability to lead through influence in a matrixed organization
• Experience performing utilization management reviews is preferred
• Experience in a health plan or managed care organization is preferred
  
  

About The Team

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield isa U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
  
  

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
• Member-facing and approved out-of-state roles remain remote.
• Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
  
  

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.