Medical Director, Utilization Management - Appeals & Grievances

Blue Shield of CA; Long Beach (CA); Hybrid; USD 180,000 - 320,000; Full time

Job summary

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

The role emphasizes leadership development, cross-functional collaboration, and ongoing learning, with hybrid virtual work and periodic office presence as needed.

Qualifications

• Requires a Medical degree (M.D./D.O.)
• Requires an active, unrestricted California State Medical License; Active and unrestricted Medical License in all additional assigned states required if assigned to other states in addition to California
• Requires 2 years of previous medical leadership experience
• Requires 5 years of direct patient care experience post residency
• Requires maintaining Board Certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice is preferred
• Demonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management and Population Health
• Completed residency in adult based primary care specialty (e.g., Internal medicine, Family practice) is preferred
• Demonstrated experience working within Commercial and Medicare health plan environments is preferred
• Extensive experience performing utilization management activities, including prior authorization, concurrent review, retrospective/post-service review, application of evidence-based clinical criteria, and medical necessity determinations in accordance with regulatory and health plan requirements
• Strong ability to comprehend and interpret medical policies and apply them consistently in clinical decision-making
• Strong written communication skills, with the ability to prepare clear, concise, and well-supported clinical determinations, appeal decisions, and professional correspondence
• Proficient in the use of computer applications and technology required to support utilization management, appeals, documentation, and data review activities
• Strong collaboration skills to effectively work with diverse, cross-functional teams to support organizational goals and successful outcomes

Responsibilities

• Clinical review of member appeals for Medicare and Commercial lines of business
• Ensure timely and compliant appeal determinations
• Prepare clear, concise, well-supported clinical determinations and appeal decisions
• Collaborate with cross-functional teams to support program goals

Skills

Medical leadership

Utilization management

Clinical decision making

Communication skills

Collaboration

Policy interpretation

Education

MD/DO

California Medical License

Residency Internal Medicine or Family Practice

Job description

Your Role

The Medical Management team ensures that Blue Shield of California (BSC) 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, Utilization Management - Appeals and Grievances is a key member of BSC's Clinical Appeals and Grievance Program, reporting directly to the Senior Medical Director of Appeals and Grievances. The position provides clinical review of member appeals for Medicare and Commercial lines of business, ensuring timely and compliant appeal determinations.

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.

Your Knowledge and Experience

• Requires a Medical degree (M.D./D.O.)
• Requires an active, unrestricted California State Medical License; Active and unrestricted Medical License in all additional assigned states required if assigned to other states in addition to California
• Requires 2 years of previous medical leadership experience
• Requires 5 years of direct patient care experience post residency
• Requires maintaining Board Certification in an ABMS or AOA recognized specialty; Internal Medicine or Family Practice is preferred
• Demonstrated proficiency in at least 3 of the following: Medicare/Medicare STARS, Dual Special Needs Plan (D-SNP), Medi-Cal, NCQA/URAC/Quality Programs, Policies/Procedures development, Clinical Subject Matter Expert for Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management and Population Health
• Completed residency in adult based primary care specialty (e.g., Internal medicine, Family practice) is preferred
• Demonstrated experience working within Commercial and Medicare health plan environments is preferred
• Extensive experience performing utilization management activities, including prior authorization, concurrent review, retrospective/post-service review, application of evidence-based clinical criteria, and medical necessity determinations in accordance with regulatory and health plan requirements
• Strong ability to comprehend and interpret medical policies and apply them consistently in clinical decision-making
• Strong written communication skills, with the ability to prepare clear, concise, and well-supported clinical determinations, appeal decisions, and professional correspondence
• Proficient in the use of computer applications and technology required to support utilization management, appeals, documentation, and data review activities
• Strong collaboration skills to effectively work with diverse, cross-functional teams to support organizational goals and successful outcomes

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.