Hybrid Medical Director, Utilization & Appeals

Blue Shield of CA; Long Beach (CA); Hybrid; USD 180,000 - 320,000; Full time

Job summary

Blue Shield of California is seeking a Medical Director for Utilization Management - Appeals and Grievances. This leader will provide clinical review of member appeals for Medicare and Commercial lines, ensuring timely, compliant determinations and strong documentation.

The role emphasizes leadership development, cross-functional collaboration, and ongoing learning, with hybrid virtual work and periodic office presence as needed.

Qualifications

• Requires a Medical degree (M.D./D.O.)
• Requires an active, unrestricted California State Medical License; Active and unrestricted Medical License in all additional assigned states required if assigned to other states in addition to California
• Requires 2 years of previous medical leadership experience
• Requires 5 years of direct patient care experience post residency
• Requires maintaining Board Certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice is preferred
• Demonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management and Population Health
• Completed residency in adult based primary care specialty (e.g., Internal medicine, Family practice) is preferred
• Demonstrated experience working within Commercial and Medicare health plan environments is preferred
• Extensive experience performing utilization management activities, including prior authorization, concurrent review, retrospective/post-service review, application of evidence-based clinical criteria, and medical necessity determinations in accordance with regulatory and health plan requirements
• Strong ability to comprehend and interpret medical policies and apply them consistently in clinical decision-making
• Strong written communication skills, with the ability to prepare clear, concise, and well-supported clinical determinations, appeal decisions, and professional correspondence
• Proficient in the use of computer applications and technology required to support utilization management, appeals, documentation, and data review activities
• Strong collaboration skills to effectively work with diverse, cross-functional teams to support organizational goals and successful outcomes

Responsibilities

• Clinical review of member appeals for Medicare and Commercial lines of business
• Ensure timely and compliant appeal determinations
• Prepare clear, concise, well-supported clinical determinations and appeal decisions
• Collaborate with cross-functional teams to support program goals

Skills

Medical leadership

Utilization management

Clinical decision making

Communication skills

Collaboration

Policy interpretation

Education

MD/DO

California Medical License

Residency Internal Medicine or Family Practice

Job description

Blue Shield of California is seeking a Medical Director for Utilization Management - Appeals and Grievances. This leader will provide clinical review of member appeals for Medicare and Commercial lines, ensuring timely, compliant determinations and strong documentation.

The role emphasizes leadership development, cross-functional collaboration, and ongoing learning, with hybrid virtual work and periodic office presence as needed.