Medical Director, Arbitrations and Utilization Management (Part Time)

Blue Shield of California•Long Beach, CA

23d•Remote

About The Position

The Medical Director, Arbitrations and Utilization Management provides clinical review and support for provider arbitrations across Commercial and Medicare lines of business and flexible Utilization Management (UM) Medical Director coverage based on operational needs. The position reports to the Sr. Medical Director, Arbitration/SIU/Mandates/Specialty Director Oversight and is part-time at 0.6 FTE. The role is part of Blue Shield’s Medical Management team, which works on medical, medication, and payment policy to support the development of a value-based health care system in California. The position also provides clinical expertise for assigned strategic and operational initiatives, supports continuity and quality of UM operations, and collaborates with clinical, operational, arbitration, and legal partners. The role permits virtual work full-time, with office attendance expected based on business need.

Requirements

Medical degree (M.D. or D.O.).
Completion of residency in an adult-based primary care specialty, such as internal medicine or family medicine, or another specialty relevant to the assigned clinical work.
Active, unrestricted California medical license.
Board certification in an ABMS-recognized specialty; Internal Medicine is preferred.
At least 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.
Knowledge of and ability to apply nationally recognized evidence-based medical necessity criteria, such as MCG or InterQual.
Ability to work independently to achieve objectives and resolve issues in ambiguous circumstances.
Clear, compelling communication skills and demonstrated ability to motivate, guide, influence, and lead others, including translating detailed analyses and complex materials into compelling communications.
Strong collaboration skills for working with diverse team members with medical, project management, and other skills.
Excellent written and verbal communication skills.
Excellent analytical, time management, and organizational skills.
Proficiency with Microsoft Excel, Outlook, Word, and PowerPoint.

Nice To Haves

Internal Medicine board certification is preferred.
Health plan, utilization management, or related medical leadership experience is preferred.

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 Blue Shield 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 and coverage needs, including SIU, mandates, and Specialty Director Oversight.
Provide UM Medical Director float coverage across Commercial and Medicare lines of business based on operational demand and coverage needs, including passing IRRs.
Perform timely clinical review and determinations for assigned pre-service, concurrent, and retrospective utilization management cases.
Apply benefit language, medical policies, and nationally recognized evidence-based medical necessity criteria consistently, and document clear clinical rationale.
Conduct peer-to-peer discussions and provide clinical consultation on complex or escalated cases, as assigned.
Support continuity of UM operations during vacancies, leaves, workload surges, and other temporary coverage needs.
Meet applicable quality, timeliness, productivity, documentation, and regulatory requirements for assigned work.
Identify clinical or operational trends and collaborate with partners on opportunities to improve consistency, quality, and member experience.
Serve as a clinical, regulatory, and quality improvement resource and clinical thought leader within the organization.
Support the Sr. Medical Director and Medical Management leaders in strategic and operational initiatives by providing clinical expertise and implementation support.
Collaborate with clinical and operational teams in implementing and operating assigned initiatives.
Understand and abide by departmental policies and procedures, the organization’s Standards of Conduct, and its Corporate Compliance Program.
Attend mandatory Corporate Compliance Program education sessions, including the annual Standards of Conduct class.
Participate actively in assigned committees and workgroups.
Abide by applicable state and federal laws and regulations.
Perform other duties as assigned.