Medical Director, Appeals & Utilization Management (Hybrid)

Blue Shield of CA; Redding (CA); Hybrid; USD 200,000 - 320,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews for member appeals across Medicare and Commercial plans, ensuring timely, compliant determinations in line with policy and quality standards.

The role emphasizes developing leaders, building high-performing teams, and collaborating across functions to support a value-based care approach, with a hybrid work setup and opportunities for professional growth.

Qualifications

• Requires an MD/DO degree and active CA medical license.
• Board certification in an ABMS or AOA recognized specialty is required.
• Leadership experience in medical settings and utilization management is required.
• Experience across commercial and Medicare health plans is preferred.

Responsibilities

• Provide clinical review of member appeals for Medicare and Commercial lines of business.
• Ensure timely and compliant appeal determinations.
• Collaborate with cross-functional teams to support Utilization Management goals.

Skills

Medical leadership experience

Direct patient care 5+ years

Utilization management

Prior authorization / chart review

Policy interpretation / medical determ

Written communication

Cross-functional collaboration

IT systems proficiency

Education

MD/DO

Active California medical license

ABMS/AOA board certification

Residency in internal medicine or family practice

Job description

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews for member appeals across Medicare and Commercial plans, ensuring timely, compliant determinations in line with policy and quality standards.

The role emphasizes developing leaders, building high-performing teams, and collaborating across functions to support a value-based care approach, with a hybrid work setup and opportunities for professional growth.