Medical Director, Arbitrations and Utilization Management (Part Time)
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 Medical Director coverage based on operational needs. The position serves as Medical Director for the provider arbitration process, reviews clinical records, and partners with Arbitration and Legal teams to prepare clinical analyses and provide testimony in arbitration proceedings. It also provides backup coverage for the Senior Medical Director across areas including SIU, mandates, and Specialty Director Oversight. The role provides UM Medical Director float coverage across Commercial and Medicare lines of business, performs clinical reviews and determinations for pre-service, concurrent, and retrospective cases, and supports continuity of UM operations during coverage gaps or workload surges. The Medical Director applies benefit language, medical policies, and evidence-based medical necessity criteria, conducts peer-to-peer discussions as assigned, and meets applicable quality, timeliness, productivity, documentation, and regulatory requirements. The position also contributes clinical expertise to strategic and operational initiatives, collaborates on implementation, participates in committees and workgroups, and serves as a clinical, regulatory, and quality improvement resource. This is a part-time position at 0.6 FTE. The role allows employees to work virtually full-time, with office attendance based on business need. The position reports to the Senior Medical Director, Arbitration/SIU/Mandates/Specialty Director Oversight.
Requirements
- Medical degree (M.D. or D.O.).
- Completed 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.
- 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; or case management or population health.
- Knowledge and skill in applying 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 to work effectively within teams of people with diverse skills, including medical and project management expertise.
- 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.
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 the Blue Shield Arbitration and Legal teams to prepare clinical analyses and provide testimony in arbitration proceedings.
- Provide backup coverage for the Senior 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 Senior 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 the implementation and operation of 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 all other duties as assigned.
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What This Job Offers
Job Type
Part-time
Career Level
Senior
Education Level
Ph.D. or professional degree
