Medical Director, Appeals & Utilization Management – Hybrid

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 250,000 - 320,000; Full time

Job summary

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews for Medicare and Commercial appeals. This role ensures timely, compliant determinations while guiding policy development and cross-functional collaboration.

The ideal candidate will bring MD/DO credentials, CA license, and 5+ years of patient care plus leadership experience in utilization management and appeals.

Qualifications

• Requires leadership experience in a medical setting.
• Experience applying evidence-based criteria and medical necessity determinations.
• Strong written communication to support determinations and appeals.

Responsibilities

• Provide clinical review of member appeals for Medicare and Commercial lines.
• Ensure timely and compliant appeal determinations.
• Develop and interpret medical policies and criteria for decisions.
• Collaborate with cross-functional teams on utilization management activities.

Skills

Medical leadership

Utilization management

Prior authorization

Medical policy interpretation

Clinical communication

Education

MD/DO degree

Tools

EMR systems

Job description

Blue Shield of California seeks a Medical Director, Utilization Management - Appeals and Grievances to lead clinical reviews for Medicare and Commercial appeals. This role ensures timely, compliant determinations while guiding policy development and cross-functional collaboration.

The ideal candidate will bring MD/DO credentials, CA license, and 5+ years of patient care plus leadership experience in utilization management and appeals.