Hybrid Medical Director, Appeals & Utilization Management

Blue Shield of California; California; Hybrid; USD 235,000 - 337,000; Full time

Job summary

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical review of member appeals for Medicare and Commercial lines in California. You will ensure timely, compliant determinations, provide clinical guidance, and contribute to cross-functional initiatives within a values-driven organization.

The role requires a medical degree, active CA license, and extensive utilization management experience, with a focus on fairness, evidence-based

Qualifications

• Requires medical degree (M.D./D.O.).
• Active California State Medical License; active/unrestricted license in other required states if applicable.
• Minimum 2 years of medical leadership experience.
• Minimum 5 years of direct patient care experience after residency.
• Board certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice preferred.
• Experience with Medicare/Medicaid, NCQA/URAC/Quality Programs, Appeals/Grievances, and utilization management.

Responsibilities

• Complete all assigned appeal reviews and adjudicate member appeals across all lines of business accurately and timely.
• Conduct independent clinical review of member appeals to assess medical necessity and benefit eligibility.
• Provide clinical consultation and subject matter expertise to internal departments.
• Apply policies, state and federal laws, and evidence-based medicine to determinations.
• Participate in peer-to-peer discussions with medical directors to review cases and reach consensus.
• Contribute to cross-functional projects, committees, and process improvements.
• Demonstrate strong clinical judgment and communication skills.
• Adhere to departmental policies, standards of conduct, and compliance programs.
• Complete mandatory training and educational requirements.
• Perform other assigned duties as needed.

Job description

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical review of member appeals for Medicare and Commercial lines in California. You will ensure timely, compliant determinations, provide clinical guidance, and contribute to cross-functional initiatives within a values-driven organization.

The role requires a medical degree, active CA license, and extensive utilization management experience, with a focus on fairness, evidence-based