Medical Director, Behavioral Health
Company: Blue Shield of California
Location: Fremont
Posted on: June 24, 2025
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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 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. 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 on projects and committees, as
necessary Your Knowledge and Experience Minimum 5 years direct
patient behavioral health clinical care experience post residency
required Medical degree (M.D./D.O.) Completed residency in
Psychiatry 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 Preferred Qualifications: Recent
inpatient psychiatric hospital experience (within the past five
years) Recent substance use disorders treatment experience (within
the past five years) 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
Deep knowledge of MHPAEA (Mental Health Parity and Addiction Equity
Act), SB855 and all regulatory and compliance requirements Managed
care experience supporting utilization management, case review,
and/or quality improvement activities in behavioral health
Experience with ASAM, LOCUS, CALOCUS, and WPATH
Keywords: Blue Shield of California, Fremont , Medical Director, Behavioral Health, Healthcare , Fremont, California
