Medical Director, Utilization & Appeals (Hybrid)

Blue Shield of CA; Lodi (CA); Hybrid; USD 250,000 - 380,000; Full time

Benefits offered by this job

Hybrid work model

Office presence as needed

Job summary

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

The role emphasizes leadership development, cross-functional collaboration, and adherence to evidence-based criteria. Hybrid virtual work model with occasional office presence supports flexibility and patient-centered care.

Qualifications

• Requires a Medical degree (M.D./D.O.)
• Active California medical license; license in all assigned states if applicable
• Minimum 2 years of medical leadership experience
• 5 years of direct patient care after residency
• Board certification maintenance in ABMS/AOA specialty (Internal Medicine or Family Practice preferred)
• Experience with Medicare/Commercial plan environments and utilization management activities
• Strong ability to interpret medical policies for clinical decisions

Responsibilities

• Provide clinical review of member appeals for Medicare and Commercial lines
• Ensure timely and compliant appeal determinations
• Develop and apply evidence-based clinical criteria and medical necessity determinations
• Prepare clear, concise, well-supported determinations and correspondence
• Collaborate with cross-functional teams to support organizational goals

Skills

Medical leadership

Clinical review

Regulatory compliance

Policy interpretation

Communication

Cross-functional collaboration

Data/documentation

Team collaboration

Education

Medical degree (M.D./D.O.)

Tools

Electronic medical records (EMR)

Job description

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

The role emphasizes leadership development, cross-functional collaboration, and adherence to evidence-based criteria. Hybrid virtual work model with occasional office presence supports flexibility and patient-centered care.