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 Medical Director, Behavioral Health will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of behavioral health concurrent review, pre- and post-service utilization review, and collaboration with Clinical Care Managers. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

Your Work 

In this role, you will: 

• Review concurrent, pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirements

• Medical decision and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely discharges

• Engage in telephonic peer-to-peer discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providers

• Train BSC utilization and care management staff which may include physicians, psychologists, nurses, social workers, and others as needed

• Perform clinical reviews to support utilization management and fraud waste and abuse case evaluations

• Participate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our members

• Participate in projects and on committees, as necessary

Qualifications

Your Knowledge and Experience 

• Medical degree (M.D./D.O.) required
• Completed an ACGME accredited residency in Psychiatry required
• Minimum 5 years direct patient behavioral health clinical care experience post residency required
• Maintain active, unrestricted California Medical License required; Maintain active, unrestricted Medical License in all additional assigned states required
• Maintain Board Certification in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP) required
• Recent inpatient psychiatric hospital experience (within the past five years)- preferred
• Recent substance use disorders treatment experience (within the past five years) preferred
• Well-versed with most areas of behavioral health services and conditions
• Show ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issues
• Experience with CPT coding, medical claims review, hospital billing, and reimbursement is strongly preferred
• Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirements is strongly preferred
• Managed care experience supporting utilization management, case review, and/or quality improvement activities in behavioral health is strongly preferred
• Experience with ASAM, LOCUS, and CALOCUS is strongly preferred

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

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 is a 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. 

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.