Medical Director, Arbitrations and Utilization Management (Part Time)

Blue Shield of CA; Redding (CA); Hybrid; USD 120,000 - 180,000; Part time

Job summary

Blue Shield of California is seeking a part-time Medical Director for Arbitrations and UM MD Float to review and support provider arbitrations across Commercial and Medicare lines. The role offers hybrid virtual work with occasional on-site needs, requiring leadership, clear communication, and expertise in evidence-based medical necessity criteria such as InterQual or MCG.

The ideal candidate holds an MD/DO, CA license, 5+ years of clinical experience, and the ability to lead diverse teams and

Qualifications

• MD or DO with medical license in California
• Residency completed in internal medicine, family medicine, or related field
• Board certification in ABMS-recognized specialty (Internal Medicine preferred)
• Minimum 5 years of direct patient care experience after residency
• Experience with utilization management, Medicare, NCQA/URAC or quality programs
• Knowledge of evidence-based medical necessity criteria (MCG/InterQual)
• Ability to work independently and resolve issues in ambiguity
• Strong written and verbal communication and leadership skills
• Proficient with Microsoft Excel, Outlook, Word, and PowerPoint

Responsibilities

• Provide clinical review and support for provider arbitrations across Commercial and Medicare lines
• Deliver flexible UM Medical Director coverage based on operational needs
• Lead and influence teams; translate analyses into actionable guidance

Skills

Communication

Collaboration

Analytical skills

Education

MD/DO degree

Tools

Microsoft Excel

Outlook

Word

PowerPoint

Job description

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Arbitrations and UM MD Float is reporting to Sr. Medical Director, Arbitration/SIU/Mandates/Specialty Director Oversight. In this role, you will provide clinical review and support for provider arbitrations across Commercial and Medicare lines of business and provide flexible UM Medical Director coverage based on operational needs.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

This is a part-time position with a 0.6 FTE schedule

Your Knowledge and Experience

• Medical degree (M.D. or D.O.) required.
• Completed residency in an adult-based primary care specialty (for example, internal medicine or family medicine) or another specialty relevant to the assigned clinical work.
• Active, unrestricted California medical license required.
• Board certification in an ABMS-recognized specialty required (Internal Medicine preferred).
• Minimum of 5 years of direct patient care experience after residency.
• Demonstrated proficiency in at least 3 of the following: utilization management, Medicare, NCQA/URAC or quality programs, medical policies and procedures, provider arbitration or litigation support, appeals and grievances, and case management or population health.
• Health plan, utilization management, or related medical leadership experience is preferred
• Knowledge of and skill in applying nationally recognized evidence-based medical necessity criteria, such as MCG or InterQual.
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analyses and complex materials into compelling communications.
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more.
• Excellent written and verbal communication skills.
• Excellent analytical, time management and organizational skills.
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint.

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.