Medical Director, Appeals & Utilization (Hybrid)

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

Job summary

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews of member appeals for Medicare and Commercial lines, ensuring timely and compliant determinations. The role reports to the Senior Medical Director of Appeals and Grievances and supports a value-based care strategy in California.

The ideal candidate will possess an MD/DO, an active CA license, 2 years medical leadership and 5+ years direct patient care, with strong policy

Qualifications

• Active California medical license required.
• 2 years of medical leadership experience.
• 5+ years direct patient care post-residency.
• Board certification in ABMS or AOA specialty required.
• Experience with Medicare/Medicaid, NCQA/URAC or quality programs.
• Experience with utilization management and prior authorization.

Responsibilities

• Provide clinical review of member appeals for Medicare and Commercial lines.
• Ensure timely and compliant appeal determinations.
• Interpret and apply medical policies consistently in decision‑making.
• Collaborate with cross‑functional teams to support outcomes.
• Develop and maintain policies and procedures for appeals/grievances.
• Lead a high‑performing medical management team.

Skills

Medical leadership

Direct patient care

Utilization management

Prior authorization

Clinical policy interpretation

Written communication

Cross-functional collaboration

Data review

Regulatory compliance

Medical terminology

Education

MD/DO degree

Active California medical license

ABMS/AOA board certification

Residency in internal medicine or family practice

Licensure in other states (if applicable)

Job description

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews of member appeals for Medicare and Commercial lines, ensuring timely and compliant determinations. The role reports to the Senior Medical Director of Appeals and Grievances and supports a value-based care strategy in California.

The ideal candidate will possess an MD/DO, an active CA license, 2 years medical leadership and 5+ years direct patient care, with strong policy