Medical Director, Appeals & Utilization (Hybrid)

Blue Shield of CA; Rancho Cordova (CA); Hybrid; USD 260,000 - 380,000; Full time

Job summary

Blue Shield of California is seeking a Medical Director, Utilization Management - Appeals and Grievances to lead clinical review of member appeals across Medicare and Commercial lines, ensuring timely and compliant determinations. This role reports directly to the Senior Medical Director of Appeals and Grievances and drives evidence-based policy application.

We value leaders who foster high-performing teams, continuous learning, and collaboration with cross-functional partners to advance

Qualifications

• Active, unrestricted California Medical License.
• 2 years of medical leadership experience.
• 5 years of direct patient care experience post residency.
• Board Certification in an ABMS or AOA recognized specialty; internal medicine or family practice preferred.
• Experience with Medicare/Medicaid programs and quality initiatives.
• Ability to interpret medical policies and apply them in clinical decisions.

Responsibilities

• Clinical review of member appeals for Medicare and Commercial lines.
• Ensure timely and compliant appeal determinations.
• Utilization management activities including prior authorization and reviews.
• Collaborate with cross-functional teams to support organizational goals.

Skills

Medical leadership

Clinical review

Appeals & Grievances

Evidence-based criteria

Communication skills

Cross-functional collaboration

Education

MD/DO

Residency in internal medicine or family practice

Board certification (ABMS or AOA)

Job description

Blue Shield of California is seeking a Medical Director, Utilization Management - Appeals and Grievances to lead clinical review of member appeals across Medicare and Commercial lines, ensuring timely and compliant determinations. This role reports directly to the Senior Medical Director of Appeals and Grievances and drives evidence-based policy application.

We value leaders who foster high-performing teams, continuous learning, and collaboration with cross-functional partners to advance