Part-Time Medical Director, Arbitration & Utilization (Hybrid)

Blue Shield of California; California; Hybrid; USD 235,000 - 337,000; Part time

Job summary

Blue Shield of California is seeking a part-time Medical Director, Arbitrations and UM MD Float to provide clinical review for provider arbitrations across Commercial and Medicare lines in California. The role supports UM operations and collaboration with Arbitration and Legal teams, with flexible float coverage based on demand.

The position is 0.6 FTE, hybrid in nature, and requires a California medical license, board certification, and extensive experience in utilization management and

Qualifications

• Medical degree (M.D. or D.O.) required.
• Completed residency in an adult-based primary care specialty or related field.
• Active, unrestricted California medical license required.
• Board certification in an ABMS-recognized specialty preferred (Internal Medicine preferred).
• Minimum of 5 years of direct patient care after residency.

Responsibilities

• Serve as Medical Director for the provider arbitration process.
• Review clinical records and provide clinical support for provider arbitrations across Commercial and Medicare lines of business.
• Partner with Arbitration and Legal teams to prepare clinical analyses and provide testimony in arbitration proceedings.
• Provide backup coverage for the Sr. Medical Director based on operational needs (SIU, mandates, Specialty Director Oversight).
• Provide UM Medical Director float coverage across Commercial and Medicare lines of business based on demand and coverage needs.
• Perform timely clinical review and determinations for pre-service, concurrent, and retrospective utilization management cases.
• Apply benefit language, medical policies, and evidence-based medical necessity criteria with clear clinical rationale.
• Conduct peer-to-peer discussions and provide clinical consultation on complex or escalated cases.

Skills

Clinical review

Arbitration support

Utilization management

Regulatory knowledge

Communication

Education

MD/DO

Residency in internal or family medicine

ABMS board certification

Tools

Excel

Outlook

Word

PowerPoint

Job description

Blue Shield of California is seeking a part-time Medical Director, Arbitrations and UM MD Float to provide clinical review for provider arbitrations across Commercial and Medicare lines in California. The role supports UM operations and collaboration with Arbitration and Legal teams, with flexible float coverage based on demand.

The position is 0.6 FTE, hybrid in nature, and requires a California medical license, board certification, and extensive experience in utilization management and