Medical Director, Utilization Management - Appeals & Grievances

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

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.