Medical Director, Appeals & Utilization Management (Hybrid)

Blue Shield of CA; Oakland (CA); Hybrid; USD 240,000 - 360,000; Full time

Job summary

Blue Shield of California is seeking a Medical Director for Utilization Management - Appeals and Grievances to lead clinical review of member appeals across Medicare and Commercial lines, ensuring timely and compliant determinations.

This senior role requires an MD/DO, active CA license, and a strong background in utilization management, policy interpretation, and cross-functional collaboration; it is a hybrid position with occasional in-office requirements.

Qualifications

• MD/DO required and board-certified in an ABMS or AOA-recognized specialty
• Active California medical license; additional state licenses as needed
• 2 years of medical leadership experience
• 5 years of direct patient care experience post-residency
• Board certification in Internal Medicine or Family Practice preferred
• Strong knowledge of Medicare/Medicare Stars, D-SNP, Medi-Cal, NCQA/URAC/Quality Programs
• Experience with utilization management activities: prior authorization, concurrent, retrospective review
• Ability to interpret medical policies and apply criteria in clinical decisions
• Strong written communication to support determinations and correspondence
• Proficiency with technology to support utilization management and data review
• Ability to collaborate with diverse, cross-functional teams

Responsibilities

• Lead clinical review of member appeals for Medicare and Commercial lines of business
• Ensure timely and compliant appeal determinations in accordance with regulations and health plan requirements
• Develop and maintain policies, procedures, and clinical criteria for appeals and grievances
• Collaborate with cross-functional teams to support organizational goals and outcomes

Skills

Clinical leadership

Utilization management

Policy interpretation

Written communication

Cross-functional collaboration

Data review

Education

MD/DO

Job description

Blue Shield of California is seeking a Medical Director for Utilization Management - Appeals and Grievances to lead clinical review of member appeals across Medicare and Commercial lines, ensuring timely and compliant determinations.

This senior role requires an MD/DO, active CA license, and a strong background in utilization management, policy interpretation, and cross-functional collaboration; it is a hybrid position with occasional in-office requirements.